Health Policy and Planning, 31, 2016, 1240–1249
doi: 10.1093/heapol/czw058
Advance Access Publication Date: 13 May 2016
Original Article
Financial sustainability versus access and quality
in a challenged health system: an examination of
the capitation policy debate in Ghana
Kilian Nasung Atuoye,1,* Siera Vercillo,1 Roger Antabe,1
Sylvester Zackaria Galaa2 and Isaac Luginaah1
1
Department of Geography, Social Science Centre, The University of Western Ontario, 1151 Richmond Street,
London, Ontario, N6A5C2, Canada, 2FIDS, University for Development Studies, Tamale, Ghana
*Corresponding author. Department of Geography, Social Science Centre, The University of Western Ontario, 1151
Richmond Street, London, Ontario, N6A5C2, Canada. E-mail: [email protected]
Accepted on 9 April 2016
Abstract
Policy makers in low and middle-income countries are frequently confronted with challenges of
increasing health access for poor populations in a sustainable manner. After several years of trying
out different health financing mechanisms, health insurance has recently emerged as a pro-poor
health financing policy. Capitation, a fixed fee periodically paid to health service providers for anticipated services, is one of the payment policies in health insurance. This article examines claims and
counter-claims made by coalitions and individual stakeholders in a capitation payment policy debate
within Ghana’s National Health Insurance Scheme. Using content analysis of public and parliamentary
proceedings, we situate the debate within policy making and health insurance literature. We found
that the ongoing capitation payment debate stems from challenges in implementation of earlier health
insurance claims payment systems, which reflect broader systemic challenges facing the health insurance scheme in Ghana. The study illustrates the extent to which various sub-systems in the policy debate advance arguments to legitimize their claims about the contested capitation payment system. In
addition, we found that the health of poor communities, women and children are being used as surrogates for political and individual arguments in the policy debate. The article recommends a more holistic and participatory approach through persuasion and negotiation to join interests and core evidence together in the capitation policy making in Ghana and elsewhere with similar contexts.
Key words: Capitation; Policy; Content analysis; health insurance; health; Ghana
Key Messages
•
•
Health insurance capitation payment policy is hotly contested in Ghana.
The need for financial sustainability while guaranteeing health access is pushing emerging health insurance in develop-
•
ing countries to implement innovative policies such as capitation.
Politics and interest outweigh evidence in policymaking in Ghana’s capitation debate, which threatens the sustainability
•
of health insurance.
Systemic and structural challenges can impede the implementation of capitation in developing countries.
C The Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.
V
All rights reserved. For permissions, please e-mail: [email protected]
1240
Health Policy and Planning, 2016, Vol. 31, No. 9
Introduction
This article examines the ongoing policy debate on the national
health insurance Capitation Claims Payment (CCP) system in
Ghana. Achieving Universal Health Coverage (UHC) has engaged
the attention of policy makers both at the global stage and in individual countries (Gosden et al. 2008; Allers and Ishemoi 2011). It
continues to be accorded important policy space in the new
Sustainable Development Goals (SDGs), which succeeded the
Millennium Development Goals (MDGs). Goal 3 of the SDGs,
which seeks to ensure healthy lives and promote wellbeing for all at
all ages, targets UHC as one of its main sub-goals (WHO 2015).
Beyond the policy imperatives, the debate remains on how to
achieve UHC, particularly in developing countries where huge gaps
in access and utilization of health care persist in a context of limited
resources for competing development needs. The challenge many developing countries face when contemplating UHC is its costs (Walt
and Gilson 1994). For countries such as Ghana that already have
UHC, effectively sustaining the programme costs has emerged as a
huge challenge. As a consequence, Ghana has been deliberating on
how best to finance its UHC in the space of competing demands.
The Ghana government proposed a capitation policy as a cost saving
measure, yet the policy itself has come under severe scrutiny and debate. This article examines the complex negotiations in policy making for sustainable implementation of UHC, and explains how
vexed positions of politics and interests of health providers are impacting on health care quality and access in developing countries.
We explain how a capitation payment policy, which is proposed to
solve the challenges of a pro-poor health insurance scheme, is facing
severe policy debate in Ghana.
Health financing is one of the critical pillars to achieving UHC
(WHO 2005). Whereas low access to health care services seems to
be well documented and defined as policy problems at global and
country levels (McIntyre et al. 2006; WHO 2014), the difficulty has
been in designing self-sustaining interventions to address these problems. Moreover, out of pocket payments for health services that
were implemented in the 1980s generally did not improve access to
health care (McIntyre et al. 2006), making health insurance a very
popular alternative policy for achieving UHC (Atim 1999; Spaan
et al. 2012).
The establishment of Ghana’s national health insurance scheme
in 2005 was a response to calls from global actors and initiatives
(the World Bank, WHO and MDGs), coalitions of local non-governmental organizations, political parties and individuals for UHC
(Durairaj et al. 2010). As a result, the health insurance policy-making process was less controversial, and devoid of competing interests
from different groups as often witnessed in public policy making
(Pal 1992). However, recent challenges in financing the NHIS have
led some to argue that the national health insurance may collapse if
the funding structure is not re-examined, which has resulted in the
introduction of a CCP policy.
Capitation is one of the many health service payment models employed to achieve health policy objectives in different countries
(Gosden et al. 2008). Capitation is a pre-payment system where a
fixed amount is given to service providers for anticipated costs of
service to clients (Agyei-Baffour et al. 2013). Until recently, this policy was predominantly practiced in the United States and other developed countries. Although several studies have examined health
insurance and its impact on health access in Ghana, there seems to
be limited literature on the NHIS policy-making process, and the impact of CCP on achievement of UHC in developing countries. This
article contributes to the literature in this regard. Specifically, the
1241
study uses content analysis to identify the rhetoric, idioms, policy
narratives and policy claims that surround the ongoing Ghana’s
health insurance policy debate and its effects on UHC.
Health financing in Ghana
Different health care service payment policies have been implemented in Ghana over the years to increase access to health care,
while guaranteeing financial sustainability. This started at independence in 1957 with the elimination of all user fees in government
health facilities. By 1969, the policy was changed to the Hospital
Fees Decree, which introduced partial payment user fees. Further
amendment was made to include user fees and charges for consultation, laboratory and other diagnostic procedures in 1971 with the
Hospital Fees Act of 1971. This Act allowed individual health service providers to fix fees and charges. The Hospital Fees Regulation
Legislative Instrument (LI 1313) was enacted in 1985 to standardize
user fees across all government health facilities (see Table 1). In addition, it introduced new fees for medical, surgical and dental services, medical examinations, and hospital accommodation. It also
made fees for drugs fully payable by the client (Nyonator and
Kutzin 1999). Invariably, the costs of health services charged to clients steadily increased from independence, which widened the disparity in health access between the rich and the poor (Nyonator and
Kutzin 1999).
Moreover, Ghana’s spending on health was around 5% of its
GDP by 2012 (see Figure 1), which was below the average spending
of countries in similar income brackets and health infrastructure
(WHO 2014). Even with the low spending levels, 43% of total
spending was private, and 67% of the total private spending portfolio was out of pocket payment (see Figure 1).
Ghana’s National Health Insurance Scheme funding
challenges
Failure of previous health financing mechanisms contributed to the
establishment of a NHIS. The National Health Insurance Act (Act
650 of 2003) and the National Health Insurance Regulation 2004
(LI 1809) are the main legislations that started NHIS in Ghana. Act
650 was amended in 2012 into Act 852 to improve the operations of
the health insurance. With these, the previous out-of-pocket payments at point of service, ‘cash and carry’, was replaced with a risk
sharing mechanism of payment where residents enrol and renew
their membership annually to access insured health coverage
(Agyepong and Adjei 2008). Studies on the link between health insurance and access and utilization of health care services have produced mixed results. Although a greater part of the literature
suggests that the introduction of the National Health Insurance
Scheme contributed to an increase in access to health care (Mensah
et al. 2010; Gobah and Zhang 2011), other studies have hinted on
the limits of the scheme in providing access to some vulnerable
populations (Dixon et al. 2011; Akazili et al. 2014). For instance,
Dixon et al. (2011) suggests that poor household members who
qualify for exemptions in the pro-poor scheme are left out becase of
weak and fuzzy indigent policy identification criteria. In addition,
Schieber et al. (2012) suggests that the NHIS was nearing bankruptcy and made recommendation for immediate financial management reforms to ensure the viability of the scheme. This call was
premised on the escalating deficits the NHIS was reporting annually.
The deficit for 2011 was 23.7% of annual income, which was an increase from 4.8% in 2009 and 15.3% in 2010 (see Figure 2) as reported in the scheme’s annual financial reports.
1242
Health Policy and Planning, 2016, Vol. 31, No. 9
Table 1. Health services utilization fee policy trends in Ghana
Time
Policy outlook
1957
1969
1971
1985
1992
1992
1995
1999
2003
2004
2012
2012
2014
Elimination of all users fees in government health facilities (at independence)
Enactment of Hospital Fees Degree-introduced user fee part payment
Hospital Fees Degree amended-expansion of user fees to cover consultation and diagnosis
Hospital Fees Regulatory-expanded and standardized user fees to cover medical, surgical and dental services
Introduction of four component fee structure including ‘cash and carry’
Establishment of Nkoranza Community Health insurance Scheme
Establishment of Gonja West District Health Insurance Scheme
Proliferation of mutual health insurance schemes
Establishment of National Health Insurance Scheme (Act 650)—abolition of ‘cash and carry’
National Health Insurance Regulation (LI. 1809)
Amendment to Act Act 658 (Act 852) to include CCP
Piloting of capitation payment system in Ashanti Region—per capita payment policy
Initiation of processes to review CCP
Note: H/C S. is health care spending and captured on the table as a percentage of GDP. Data are sourced from the World Bank and the World Health
Organization.
Figure 1. Trends in health expenditure in Ghana from 1995 to 2012.
Figure 2) because of the implementation of cost containment strategies, including the CCP and strengthening of claims processing as a
way to minimize fraud.
The CCP is being implemented at the primary health care level
after a pilot phase in the Ashanti Region in 2012 supported by the
World Bank. The piloting phase was heralded by intense debate
about the advantages and disadvantages of the policy to attain
UHC. This article identifies claims made by coalitions, individual
stakeholders and how this policy debate impacts UHC.
Deficit in NHIS Accounts (2009-2012)
25.00
23.70
Percentages
20.00
15.27
15.00
10.00
5.00
4.80
1.87
0.00
2009
2010
2011
Theoretical context
2012
The capitation payment system in health insurance
Figure 2. NHIS deficit as a percentage of total revenue (2009–12).
In 2012, the health insurance scheme suggested in their report
that a combination of factors including ‘moral hazards’, in other
words, financial mismanagement could be accounting for the rising
deficits. Consequently, the deficit in 2012 dropped to 1.9% (see
The debate on the capitation payment model in Ghana emanates
from a number of inherent uncertainties. The amount of risk that
would be shifted to health facilities, physicians and patients; the criteria for calculating payments; and the extent to which capitation
would affect the quality of and access to health care are the key
uncertainties that are debated in the capitation policy making
Health Policy and Planning, 2016, Vol. 31, No. 9
(Berwick 1996). The principal assumption of the capitation payment
system is based on predictive utilization of health care services.
Fixed payments to health providers are based on health care cost estimates per subscriber over a period of time. Under this arrangement, a service provider is disadvantaged when the cost of service
provided over a period of time is higher than the capitation payment
made.
The effect of capitation on UHC is explained by two counter theoretical positions. The first suggests that physicians would manoeuvre to avoid or reduce financial risk under capitation, despite
guidelines and rules made on health care provision (Hillman 1987;
Goldfarb 1995; Gosden et al. 2008). The second argues that capitation has the potential to improve coordination and inter-linkages between insurance companies and services providers (Berwick 1996).
It also promotes preventive health to reduce the costs of health service and improve health of a population (Chaix-Couturier et al.
2000; Fried et al. 2000). Empirical research has shown varied results
on the consequences of capitation in different contexts (see Lurie
et al. 1994; Chaix-Couturier et al. 2000), thereby making it an intensely debated policy strategy.
1243
because it can produce rhetorical landscapes, important for identifying trends in policy decision-making processes (Howland et al.
2006).
Data sources
The data for the study included transcripts from the deliberations of
the Parliament of Ghana—Hansard—and media articles. Both private and public media houses provide large and diverse media spaces
for debates. The study also gathered data from private radio and
newspaper online platforms (peacefmonline.com, myjoyonline.com,
citifmonline.com, myradiogoldlive.com, chronicle.com.gh, dailyguideghana.com and modernghana.com) and public news platforms
(gbcghana.com, ghananewsagency.org and graphic.com.gh).
Articles were also drawn from the websites of the Ghana Medical
Association (GMA), the National Health Insurance Authority
(NHIA), the Ministry of Health, and the Government of Ghana.
The varied data sources are useful in providing a comprehensive
capture of the debate around the CCP policy.
Policymaking with evidence and politics
Data collection
This article is situated within a conceptualization that holds policy
making as evidence and politics driven, and involving complex relationship of actors. The overall notion is that politics and evidence
are interdependent and interconnected in policymaking (Dunn
1981; Pielke 2007; Russell et al. 2014).
According to Sabatier (1987), policy sub-systems are those actors
from a variety of public and private organizations who are actively
concerned with a policy problem or issue and work to influence its
direction. These go beyond administrative agencies, legislative committees and interest groups to include researchers, journalists, and
other non-core policy actors. Actors form coalitions based on shared
values, evidence or knowledge to advance their collective policy
claim in policy arguments using rhetoric in narratives that depict
their varied evidence (Sabatier 1987; Russell et al. 2014). Dunn
(1981) acknowledges that different policy claims can be drawn from
the same policy knowledge depending on the assumptions in the policy debate. This article identifies different actors, their claims, narratives and rhetoric in the policy debate around the contested CCP
policy in Ghana’s NHIS with a broad objective of explaining some
of the dimensions of CCP policy making in emerging health insurance schemes in developing countries. The following specific questions were asked to achieve the broad study objectives: (a) Which
actors are key contributors to the national health insurance debate
and what process do they use? (b) What are the main claims in the
capitation debate and how are they articulated? (c) What are the
rhetorical stratagems in the policy narratives?
Data collection took two forms. First, a search was conducted on
the website of the Parliament of Ghana to identify specific parliamentary sittings that discussed CCP. Following that, Hansard and
news articles from media platforms were pulled out for analysis.
The basic search criteria were that ‘capitation in health insurance
was mentioned’ and ‘there was some debate on it’. The search resulted in 52 unique news stories and five Hansards from January
2012 to November 2014. Five rounds of search were conducted at
2-week intervals, on 10 and 24 October, the 7 and 21 November,
and the last search on 5 December. Figure 3 illustrates the schema of
selecting news articles.
Materials and methods
Content analysis
This study uses Howland et al. (2006) analysis framework, which
merges content analysis with the policy analytical framework developed by Lasswell (1971). It also adopts rhetorical analysis by
Krippendorff (2012) in order to identify stakeholders, policy claims,
narratives and rhetoric used in the CCP debate in Ghana. We used
content analysis in order to answer the research questions. Content
analysis allows for systematic reading of a body of texts, images and
symbolic matter (Lasswell 1971). It is best suited for this study
Data analysis
Identification of claims
The identification of claims involved manually going through each
news article and Hansard selected for the study. This was effective
in identifying both explicit and implicit policy claims about the
CCP. Similar to Mkandawire et al. (2010), to identify substance in
claims, we looked for connecting words such as ‘because’, ‘thus’,
‘hence’ as they serve as transitions from policy claims to the substance of the claim. In order to answer the ‘what’ parts of our research questions and provide a description of the key actors, their
claims and the processes they used, numeric summaries are provided
in the results section.
Coding policy claims and direction of policy arguments
A frame containing all possible codes and descriptions were developed after an initial reading of all articles to identify emerging
themes and the direction of the debate. Pro-CCP were coded ‘P’ and
anti-capitation coded ‘A’. We also coded the substance and main
interest underwriting the claims in the arguments. International best
practices, economics, efficiency in claims payment and health care
delivery, politics, discrimination, and access to health care were
coded as ‘I’, ‘E’, ‘Ef’, ‘Po’ ‘D’ and ‘H’, respectively. The two antagonizing policy claims were linked to the six substances to form twelve
permutations as illustrated in Table 2.
1244
Health Policy and Planning, 2016, Vol. 31, No. 9
Figure 3. Flow diagram showing data collection process.
Results
Table 2. Codes for claims and substance
Policy claims
Code
Pro-capitation
Anti-capitation
Policy Substance
International practice
Economic
Efficiency
Political
Discrimination
Health access
Permutation
Pro-capitation/international practice
Pro-capitation/economic
Pro-capitation/efficiency
Pro-capitation/political
Pro-capitation/discrimination
Pro-capitation/health access
Anti-capitation/international practice
anti-capitation/economic
Anti-capitation/efficiency
Anti-capitation/political
Anti-capitation/discrimination
Anti-capitation/health access
P
A
I
E
Ef
Po
D
H
PI
PE
PEf
PPo
PD
PH
AI
AE
AEf
PPo
AD
AH
Actors and coalitions in the Capitation Payment Policy
debate
Our analysis identified key active Members of Parliament (MP) as
major contributors to the debate. The Parliament of Ghana is organized into majority and minority sides, and debates are mostly divided along partisan affiliations. Coincidentally, the majority and
minority sides represent the political party in government and the
main opposition party, respectively. In the capitation policy debate,
MPs from the Ashanti Region, where the policy was piloted, were
very vociferous both in and outside parliament. This group was
mainly from the minority side in parliament. Health service provider
groups such as the GMA, Insurance Service Providers Association of
Ghana (HISPAG), the Pharmaceutical Society of Ghana (PSG) and
laboratory technicians were active participants in the debate. The
NHIA and the Ministry of Health were other key actors in the debate. The involvement of many subsystems from different backgrounds signifies the complexity and messy nature of the policy
making process (Dunn 1981). Although the pro-capitation actors
were mainly interested in cost containment, the anti-capitation
group was resisting change in the payment policy because of uncertainties about the effect of the new policy on their incomes.
The pro-capitation coalition included the NHIA and the
Government (the Executives), while the anti-capitation coalition
Health Policy and Planning, 2016, Vol. 31, No. 9
1245
Table 3. Summary results from pro and anti-capitation coalitions
Position in debate
n
Pro-Capitation
Anti-Capitation
Total
Medium of communication used
29
60
89
Pro-capitation
n
Private Radio
Public Radio
Public Newspaper
Hansard
Private Newspaper
Total
Form of communication
Interview
Press release
Press conference
Parliamentary debate
Public speech
Petition
Demonstration
Total
Substance of claims
Health access
Economic
Efficiency
Political
International best practice
Discriminatory
Total
Percent
32.6
67.4
100
Anti-capitation
5
10
8
6
0
29
Percent
17.2
34.5
27.6
20.7
0.0
100
13
5
2
6
3
0
0
29
3
6
9
4
7
0
29
32
10
8
4
6
60
Percent
53.3
16.7
13.3
6.7
10.0
100
44.8
17.2
6.9
20.7
10.3
0.0
0.0
32.6
28
7
9
4
6
3
3
60
10.3
20.7
31.0
13.8
24.1
0.0
32.6
26
22
2
5
0
5
60
included HISPAG, GMA, PSG, prominent individuals and pressure
groups. The parliament of Ghana was divided into pro-capitation
(the majority side) and anti-capitation (the minority side). Out
of the total claims that emerged from the study, 67.4% were anticapitation, which seemed to suggest a robust debate from the anticapitation coalition side. Private radio stations carried 41.6% of the
claims and majority of the claims (46.1%) were made through interviews. The most assigned substance to the claims was health access
(32.6%). Tables 3 and 4 illustrate summaries of our findings.
The pro-capitation policy claims
The NHIA was the top contributor to the debate, generating 41.4%
of all pro-capitation claims. Public radio was the most patronized
medium of communication. Approximately 35% of the claims in
support of the capitation were routed through it. This is expected
since the main public radio platform; the Ghana Broadcasting
Cooperation is charged with the duty of educating citizens about
government’s policies and has a wider geographical coverage in
Ghana. Moreover, 44.8% of all claims made by this coalition were
through interviews. This article categorizes the substance underwriting various claims into evidence and non-evidenced based.
Evidence-based substances in pro-capitation claims
Pro-capitation claims hinged on access to health care, sustainability
and efficiency, constituting 10.3, 20.7 and 31.0%, respectively. The
main argument was that capitation was implemented to give the insurance scheme new breath, free it from abuse and fraud, while
strengthening systems to make it sustainable. This position is captured in the statement made by a health economist: ‘. . . considering
the expansive coverage of the NHIS and the scheme’s objective to
n
Total (n)
37
20
16
10
6
89
Percent (total)
41.6
22.5
18.0
11.2
6.7
100.0
46.7
11.7
15.0
6.7
10.0
5.0
5.0
67.4
41
12
11
10
9
3
3
89
46.1
13.5
12.4
11.2
10.1
3.4
3.4
100.0
43.3
36.7
3.3
8.3
0.0
8.3
67.4
29
28
11
9
7
5
89
32.6
31.5
12.4
10.1
7.9
5.6
100.0
attain UHC, capitation is the best payment model to ensure sustainability (deleted: whiles ensuring that) [and] quality of care. (delete:
is also guaranteed)’ (Comment no. 13, PEf). Others also explained
that capitation was being introduced to improve the management of
claims payment as indicated in the statement: ‘. . . capitation had to
be introduced to help streamline operational deficiencies detected in
the implementation of the NHIS’ (Comment no. 52, PEf) and also
remove fraud. ‘The introduction of capitation was . . . to clear the
system of corruption and the pilot has proven successful in achieving
that’ (Comment no. 23, PEf).
Moreover, claims payment was mostly in arrears and supporters
of the capitation policy argued that the policy would solve the problem of late payment. Speaking in parliament, the Health Minister
stated: ‘the capitation system ensures that per capita payment is
made within the first week of the month. It allows for payment to
providers to be made before services are delivered. It therefore remains the best mechanism for avoiding delays in payment of claims
for services rendered’ (Comment no. 17, PEf). The World Bank and
the International Monitoring Fund also lent their support to the
capitation policy, with a conviction that: ‘capitation is one of the
approaches that can increase efficiency and reduce cost, and any
country that is implementing a health insurance policy must strive to
do that’ (Comment no. 8, PEf).
Financial sustainability and accountability surfaced strongly in
the debate. Considering the contribution of health insurance to the
access and utilization of health care, citizens were likely to support
policies that would assure the economic sustainability of the scheme.
The proponents of capitation clearly articulated this position:
Mr. Speaker, once you have a claim, and it should always be predetermined, you are helping the provider in some case to improve
1246
Health Policy and Planning, 2016, Vol. 31, No. 9
Table 4 Results based on actors in capitation policy debate
Actors in debate
HISPAG
n (%)
Medium of communication used
Private radio
11 (29.7)
Public radio
1 (5.0)
Private newspaper
2 (33.3)
Public newspaper
3 (18.8)
Hansard
0 (0.0)
Total
17 (19.1)
Substance of claims
Political
0 (0.0)
Economic
9 (32.1)
Efficiency
2 (18.2)
Best practice
0 (0.0)
Health access
6 (20.7)
Discriminatory
0 (0.0)
Total
17 (19.1)
Form of engagement
Press release
2 (16.7)
Petition
1 (33.3)
Interview
9 (22.0)
Public speech
2 (22.2)
Press conference
3 (27.3)
Demonstration
0 (0.0)
Debate
—
Total
17 (19.1)
Position in debate
Pro-capitation
0 (0.0)
Anti-capitation
17 (18.3)
Total
17 (19.1)
GMA
n (%)
NHIA
n (%)
PG
n (%)
Parl.
n (%)
Gov’t
n (%)
PSG
n (%)
Ind.
n (%)
Total (%)
9 (24.3)
3 (15.0)
1 (16.7)
3 (18.8)
0 (0.0)
16 (18.0)
3 (8.1)
4 (20.0)
0 (0.0)
5 (31.3)
0 (0.0)
12 (13.5)
8 (21.6)
1 (5.0)
2 (3.33)
1 (6.3)
0 (0.0)
12 (13.5)
0 (0.0)
1 (5.0)
0 (0.0)
0 (0.0)
10 (100)
11 (12.4)
1 (2.7)
5 (25.0)
0 (0.0)
3 (18.8)
0 (0.0)
9 (10.1)
1 (2.7)
4 (20.0)
0 (0.0)
1 (6.3)
0 (0.0)
6 (6.7)
4 (10.8)
1 (5.0)
1 (16.7)
0 (0.0)
0 (0.0)
6 (6.7)
37 (41.6)
20 (22.5)
6 (6.7)
16 (18.0)
10 (11.2)
89 (100)
0 (0.0)
5 (17.9)
0 (0.0)
0 (0.0)
11 (37.9)
0 (0.0)
16 (18.0)
1 (11.1)
2 (7.1)
5 (45.5)
3 (42.9)
1 (3.4)
0 (0.0)
12 (13.5)
4 (44.4)
1 (3.6)
0 (0.0)
0 (0.0)
2 (6.9)
5 (100.0)
12 (13.5)
1 (11.1)
2 (7.1)
0 (0.0)
3 (42.9)
5 (17.2)
0 (0.0)
11 (12.4)
1 (11.1)
3 (10.7)
3 (27.3)
1 (14.3)
1 (3.4)
0 (0.0)
9 (10.1)
0 (0.0)
6 (21.4)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
6 (6.7)
2 (22.2)
0 (0.0)
1 (9.1)
0 (0.0)
3 (10.3)
0 (0.0)
6 (6.7)
9 (10.1)
28 (31.5)
11 (12.4)
7 (7.9)
29 (32.6)
5 (5.6)
89 (100)
3 (25.0)
1 (33.3)
5 (12.2)
3 (33.3)
4 (36.4)
0 (0.0)
—
16 (18.0)
3 (25.0)
0 (0.0)
7 (17.1)
2 (22.2)
0 (0.0)
0 (0.0)
—
12 (13.5)
2 (16.7)
1 (33.3)
5 (12.2)
0 (0.0)
1 (9.1)
3 (100)
—
12 (13.5)
0 (0.0)
0 (0.0)
1 (2.4)
0 (0.0)
0 (0.0)
0 (0.0)
10 (100)
11 (12.4)
2 (16.7)
0 (0.0)
4 (9.8)
1 (11.1)
2 (18.2)
0 (0.0)
—
9 (10.1)
0 (0.0)
0 (0.0)
4 (9.8)
1 (11.1)
1 (9.1)
0 (0.0)
—
6 (6.7)
0 (0.0)
0 (0.0)
6 (14.6)
0 (0.0)
0 (0.0)
0 (0.0)
—
6 (6.7)
12 (13.5)
3 (3.4)
41 (46.1)
9 (10.1)
11 (12.4)
3 (3.4)
10 (11.2)
89 (100)
0 (0.0)
16 (26.7)
16 (18.0)
12 (41.4)
0 (0.0)
12 (13.5)
0 (0.0)
12 (20.0)
12 (13.5)
6 (20.7)
5 (8.3)
11 (12.4)
9 (31.0)
0 (0.0)
9 (10.1)
0 (0.0)
6 (10.0)
6 (6.7)
2 (6.9)
4 (6.7)
6 (6.7)
29 (32.6)
60 (67.4)
89 (100)
Note: HISPA, Health Insurance Service Providers Association of Ghana; GMA, Ghana Medical Association; NHIA, National Health Insurance Authority; PG,
Pressure Group; Parl., Parliament; Gov’t, Government; PSG, Pharmaceutical Society of Ghana; Ind., individuals.
upon the conditions of that facility to be able to maintain the
kind of clientele coming to that provider. Above all, capitation is
helping us to cut down on all the expenses that are being incurred
by the Scheme which are trying to break it down (Comment no.
31, PE).
This statement is supported with an expert’s position that ‘capitation can play an important part in cost containment for the NHIS’
(Comment no. 17, PE). While experts communicated the benefits of
capitation with some degree of uncertainty by using phrases such as
‘can play’, government and the NHIA were emphatic in the prospects of the policy in cost reduction.
Meanwhile, the debate also put forth arguments on the effect of
the policy on access to health care. The proponents were aware of
the socio-political context and realized that associating the capitation policy with potential increase in access to health care would
garner support for the policy as illustrated in the statement: ‘the
capitation is including Community-Based Health Planning and
Services (CHPS) Compounds in the scheme. It would give many people access to basic health care, since CHPS Compounds, which
make up 56% of health facilities in the country are closer to people’
(Comment no. 55, PH).
The politics in the pro-capitation claims
Notwithstanding the use of evidence in claims making, politics were
also part of the claims made by the pro-capitation group. For instance, in supporting the argument that capitation would not affect
free maternal and childcare services program already provided
under the NHIS, a regional manager of NHIS at a press conference
emphasized: ‘maternal and child health services continue to be free.
They are not even part of the capitation policy and there is no way
capitation will have an effect on maternal and child health care [services] because we take the health of mothers and children seriously’
(Comment no. 71, PPo). This seems to suggest that besides maternal
and child health, other health services were not to be taken seriously. Politics formed 13.8% of all the substance in policy claims
from the pro-capitation coalition, and much higher than access to
health care as a claim.
The anti-capitation policy claims
The debate from the anti-capitation coalition was dominated by
submissions from the GMA. Out of a total of 60 anti-capitation
claims, 26.7% were from the GMA. Other pressure groups contributed 20% and prominent individuals advanced the least number of
statements (see Table 4). Most of the claims were made over private
radio channels (53.3%). Interview was the most preferred form of
communicating claims (46.7%). Although demonstrations and petitions were used, they were the least patronized in communicating
claims to the public.
The substances behind the claims were emphatically around
health access and economic concerns. Forty-seven percent of the
claims touched on the effect of capitation on access to health care,
while 36.7% were on the extent to which capitation was reducing
the amounts that service providers receive. Again, we present the
substance behind the claims advanced by the anti-capitation coalition in two categories: evidence and politics based.
Health Policy and Planning, 2016, Vol. 31, No. 9
Evidence-based claims in anti-capitation claims
The overwhelming substance in the claims was that capitation policy
was increasing the cost of accessing health care services because
facilities were turning subscribers away or asking for out-of-pocket
payments. An MP from the minority side stood his ground to make
this point during a debate on the capitation policy in Parliament.
Mr. Speaker, unfortunately, since health insurance was introduced in Ghana, there has been a well-correlated reduction in
our out-of-pocket expenditure. . . . when ‘Capitation’ was introduced in the Ashanti Region, a very marked increase in out-ofpocket expenditure was observed. Mr. Speaker, the Eastern
Region has always been used as comparator when the regions are
being studied with the Ashanti Region. Mr. Speaker, in the studies that the National Health Insurance Authority itself did, it was
found out that whereas the out-of-pocket expenditure in the
Eastern Region was 36 per cent, in the case of the Ashanti
Region it has gone up to 64 per cent. Mr. Speaker, that tells you
that there is something wrong. And if you look at the two environments, the only difference is that there has been this change of
the introduction of the capitation (Comment no. 59, AE).
The anti-capitation coalition argued that health facilities are insisting on fees because they were receiving lesser amounts as fees
under capitation compared with what they were receiving under previous claims payment systems.
The coalition put out the potential effect of the capitation policy
on the quality of health care services to convince the public that the
capitation policy was not good for the country. Previous payment
systems concentrated risk at the NHIA. A press release from the
GMA explained how limiting capitation was to the provision of
health care services.
Most doctors in the facilities feel handicapped in their ability to
effectively treat their patients since it is the scheme that invariably dictates to the doctor the manner in which the patient
should be managed. This involves the kind of investigations to be
done and the type of medication to be prescribed. In some instances doctors are instructed to refer patients to lower health
care facilities for re-referral back to the same doctor before certain medicines can be prescribed’ (Comment no. 3, AEf).
A physician in an interview at a private radio outlet commented
on how quality can be compromised: ‘Reimbursing facilities for far
less than the resources used in treating the patient, while simultaneously frowning on co-payment, the NHIA was creating an untenable situation, which had ultimately created a system of
compromised quality care’ (Comment no. 40, AEf).
Capitation is applied to facilities that render primary health care
and these are greatly patronized by the poor and vulnerable, who
are more likely to be greatly affected by challenges in the implementation of the capitation policy. A former Chief Executive Officer of
Komfo Anokye Teaching Hospital, a prominent hospital indicated:
‘replication of the capitation policy in other regions will be disastrous to the nation, especially in the three Northern Regions where
poverty is endemic’ (Comment no. 77, AEf). A public health expert
in a similar comment indicated that the implementation of the capitation policy would negatively affect some categories of health facilities: ‘Small facilities such as maternity homes and CHPS compounds
need help to survive under the capitation’ (Comment no. 64, AEf).
The politics in the anti-capitation claims
Politicians under the cover of pressure groups seemed to advance
their hidden interests to gain political points and make the government unpopular. An interview granted by a leading member of the
1247
Public Action Against Corruption and Abuse, a pressure group,
linked the capitation being piloted in the Ashanti region to the
following:
Maternal mortality is on the ascendancy. Figures will soon indicate that infant mortality is going up as well. Ghana risk eroding
the gains it has made over the years in health delivery if the policy
is allowed to continue. In fact capitation has the tendency to affect the life expectancy level of the whole country. The President
must act now (Comment no. 62, APo).
Other comments from the debate included, ‘The introduction of
the capitation system is meant to kill people,’ (Comment no. 33,
APo), ‘Why should you keep on implementing a policy when the
people who are supposed to benefit are crying and calling for its abrogation,’ (Comment no. 69, APo) and ‘capitation is unfair, discriminatory and designed to undermine quality healthcare delivery. . .’
(Comment no. 21, APo).
Discussion
In an attempt to find a sustainable way of funding Ghana’s NHIS
and also to reduce waste, the government piloted the capitation policy. The capitation policy has become a hotly debated issue between
the NHIA and government on one side, and service providers and
pressure groups on the other. This debate is fuelled by the inherent
uncertainties in the determination of a per capita fee. In comparison
with previous claim payment schemes, capitation paid lower
amounts as claims, and stakeholders (particularly service providers)
did not understand the ‘scientific formula’ used in arriving at the
various amounts. Absence of certainty in determining rates for
claims payments allows politics and individual interests to filter into
the capitation policymaking. In addition, it became apparent that although capitation had the potential of reducing costs (a position favoured by funders), it also had the potential of reducing access to
health care and could compromise the quality of health delivery
(a position favoured by anti-capitation coalitions) (Schneider and
Hanson 2007). Capitation could be described as a complex policy
issue with a plethora of uncertainties relating to fixing of a per unit
payment, financial risk to various stakeholders and the effect that
would have on quality of health care. These uncertainties promote
emergence of politics, values and interests in the debate (Dunn
1981).
In the midst of uncertainties emerged the formation of coalitions
based on various interests to debate and present claims and counterclaims with rhetoric to convince the public that the capitation policy
was the best or was the worst to have happened to health insurance
in the country. Institutions and individuals who typically would not
belong to the same group were supporting each other to advance
their positions. For instance, the regional health directorate of the
Ashanti Region, which is under Ghana Health Service, a government
institution, joined the anti-capitation coalition to debate the
Ministry of Health and NHIA. They shared the same motivation to
oppose the capitation policy implementation with the anti-capitation coalition. We equally observe the disintegration of some of the
groups and the nullification of others at certain times of the debate.
This resonates with Pal (1992)’s analysis of coalitions in policy
making.
Notwithstanding the uncertainty around the capitation policy,
each coalition tried to advance their claims based on some evidence.
Although the pro-capitation coalition emphasized that capitation
had been shown to guarantee the sustainability of health insurance
across the world without compromising quality (Castano and Mills
1248
2013; Robyn et al. 2013; Tangcharoensathien et al. 2015), the anticapitation coalition argued that even in the pilot phase, capitation
was not working, and will therefore be disastrous for health care
when rolled out across the country. Interestingly, the substance behind most claims emphasized the effects on access to health care and
the extent to which access by vulnerably populations was used as a
surrogate by both sides to reinforce their policy claims (Sabatier
1987; Roe 1994). Invariably, the two positions in the debate are
aligned to theoretical and empirical literature (Hillman 1987;
Goldfarb 1995; Gosden et al. 2008). For instance, Lurie et al.
(1994) found in a randomized study that there was no difference between patients on a fee for service and those on capitation with respect to the number of deaths and the proportions reporting poor
health. They however, found that patients on capitation payments
reported better general health and wellbeing scores compared with
those on fee for service. In contrast, Sun et al. (2014) suggests that
capitation reforms in rural China could not sustain cost containments after the first few months of implementation.
The CCP is an output of policy making under pressure to sustain
health insurance within a distressed Ghanaian economy. In this context, evidence is likely to play a very minimal role in policy decisions
(Dunn 1981; Roe 1994). We observed the unrelenting position of
policy makers and the governing party stacked against the anti-capitation group. Furthermore, the mixed results bring to the fore the
important role of context (Pal 1992). Although capitation may contain costs in the USA as shown by Bloom et al. (2011), Sun et al.
(2014) found that it could only achieve cost containment in the first
two years of implementation in rural China. Poor coordination and
weak linkages between health providers and the NHIA, and poor record keeping and management may pose real challenges in effective
estimation of the per capita payment system in Ghana. As indicated
by the results, information on the criteria used in estimating the per
capita fee was limited during the debate. In addition, ensuring that
capitation does not unduly increase the cost of accessing and utilizing quality health care could be very difficult in a poorly coordinated and networked health system as in the case of Ghana.
Limitation of the study
The results in this study may not be exhaustive of the actors, their
claims and substances in the capitation policy debate. This notwithstanding, the results capture the main actors, their claims and the
processes used in engaging each other and the Ghanaian public on
CCP.
Conclusion
Capitation within the NHIS in Ghana is a messy policy issue, which
has gone through intense debate involving different actors that are
arranged in complex relationships. Pal (1992) explained that policymaking becomes more complex as the number of actors in the process goes beyond two. In the capitation policy debate more than 10
key stakeholders took part and engaged with each other over two
main coalitions. The anti-capitation coalition’s description of challenges faced by the health insurance as systemic made the debate
messy and multi-dimensional. The CCP seems only to be a part of
the problem. Poor coordination and networking between health
facilities and NHIS, poor and laborious record keeping and retrieval
at health facilities, and absence of robust monitoring systems are
some of the challenges which should be addressed to strengthen systems and processes for smooth implementation of health insurance.
Health Policy and Planning, 2016, Vol. 31, No. 9
We notice in the debate that other measures such as biometric registration of health insurance clients were being implemented alongside
the CCP to improve coordination.
The findings from this policy analysis provide useful lessons for
other developing countries that may be considering implementation
of capitation in their national health insurance schemes. We suggest
that implementation of CCP have to start with strengthening of
transparency and accountability systems within health insurance,
and building networks of actors in the health insurance environment
to improve coordination. We note that capitation policy making
cannot be devoid of politics, values and interest of various actors,
hence, greater participation through persuasion and negotiation
could join interests and core evidence together to produce a more acceptable public policy for improved health care.
Acknowledgements
We wish to thank Dr. Frederick Ato Armah and Alexander Angsogna for their
critical feedback on earlier drafts of this article. We are also grateful for the
complementary and critical reviews from our anonymous reviewers.
Conflict of interest statement. None declared.
References
Agyei-Baffour P, Oppong R, Boateng D. 2013. Knowledge, perceptions and
expectations of capitation payment system in a health insurance setting: a
repeated survey of clients and health providers in Kumasi, Ghana. BMC
Public Health 13: 1220.
Agyepong IA, Adjei S. 2008. Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme. Health
Policy and Planning 23: 150–60.
Akazili J, Welaga P, Bawah A et al. 2014. Is Ghana’s pro-poor health insurance scheme really for the poor? Evidence from Northern Ghana. BMC
Health Services Research 14: 637.
Allers MA, Ishemoi LJ. 2011. Equalising spending needs of subnational governments in a developing country: the case of Tanzania. Environment and
Planning C: Government and Policy 29: 487–501.
Atim C. 1999. Social movements and health insurance : a critical evaluation of
voluntary, non-profit insurance schemes with case studies from Ghana and
Cameroon. Social Science and Medicine 48: 881–96.
Berwick DM. 1996. Payment by capitation and the quality of care. New
England Journal of Medicine 335: 1227–31.
Bloom JR, Wang H, Kang SH et al. 2011. Capitation of public mental health
services in Colorado: a five-year follow-up of system-level effects.
Psychiatric Services (Washington, D.C.) 62: 179–85.
Castano R, Mills A. 2013. The consequences of hospital autonomization in
Colombia: a transaction cost economics analysis. Health Policy and
Planning 28: 157–64.
Chaix-Couturier C, Durand-Zaleski I, Jolly D, Durieux P. 2000. Effects of financial incentives on medical practice: results from a systematic review of
the literature and methodological issues. International Journal for Quality
in Health Care : Journal of the International Society for Quality in Health
Care/ISQua 12: 133–42.
Dixon J, Tenkorang EY, Luginaah I. 2011. Ghana’s National Health
Insurance Scheme: helping the poor or leaving them behind? Environment
and Planning C: Government and Policy 29: 1102–15.
Dunn W. 1981. Public Policy Analysis. New Jersey: Prentice Hall.
Durairaj V, D’Almeida S, Kirigia J. 2010. Ghana’s approach to social health
protection: Background Paper, 2. In: Health Systems Financing: The path to
Universal Coverage. World Health Report (2010). Geneva: World Health
Organisation.
Fried BJ, Topping S, Morrissey JP, et al. 2000. Comparing provider perceptions of access and utilization management in full-risk and no-risk Medicaid
programs for adults with serious mental illness. The Journal of Behavioral
Health Services & Research 27: 29–46.
Health Policy and Planning, 2016, Vol. 31, No. 9
Gobah FK, Zhang L. 2011. The National Health Insurance Scheme in Ghana:
Prospects and Challenges: a cross-sectional evidence. Global Journal of
Health Science 3: 90–101.
Goldfarb S. 1995. Physicians in control of the capitated dollar: Do unto others. . .. Annals of Internal Medicine 123: 546–7.
Gosden T, Forland F, Kristiansen I et al. 2008. Capitation, salary, fee-forservice and mixed systems of payment: Effects on the behaviour of primary
care physicians. Chinese Journal of Evidence-Based Medicine 8: 416–7.
Hillman AL. 1987. Financial incentives for physicians in HMOs. New
England Journal of Medicine 317: 1743–8.
Howland D, Becker ML, Prelli LJ. 2006. Merging content analysis and the
policy sciences: A system to discern policy-specific trends from news media
reports. Policy Sciences 39: 205–31.
Krippendorff K. 2012. Content Analysis: An Introduction to the
Methodology. Thousand Oaks: Sage.
Lasswell HD. 1971. A Pre-View of the Policy Sciences. New York: American
Elsevier.
Lurie N, Christianson J, Finch M, Moscovice I. 1994. The effects of capitation
on health and functional status of the Medicaid elderly: a randomized trial.
Annals of Internal Medicine 120: 506–11.
McIntyre D, Thiede M, Dahlgren G, Whitehead M. 2006. What are the economic consequences for households of illness and of paying for health care
in low- and middle-income country contexts? Social Science and Medicine
(1982) 62: 858–65.
Mensah J, Oppong JR, Schmidt CM. 2010. Ghana’s National Health
Insurance Scheme in the context of the health MDGs: an empirical evaluation using propensity score matching. Health Economics 19: 95–106.
Mkandawire P, Luginaah IN, Bezner-Kerr R. 2010. Deadly divide: Malawi’s
policy debate on HIV/AIDS and condoms. Policy Sciences 44: 81–102.
Nyonator F, Kutzin J. 1999. Health for some? The effects of user fees in the
Volta Region of Ghana. Health Policy and Planning 14: 329–41.
Pal LA. 1992. Public Policy Analysis: An Introduction. Scarborough: Nelson
Canada.
1249
Pielke RAJ. 2007. The Honest Broker: Making Sense of Science in Policy and
Politics. Cambridge: Cambridge University Press.
Robyn PJ, Sauerborn R, B€
arnighausen T. 2013. Provider payment in community based health insurance schemes in developing countries: a systematic review. Health Policy and Planning 28: 111–22.
Roe E. 1994. Narrative Policy Analysis: Theory and Practice. Durham, NC:
Duke University Press.
Russell J, Greenhalgh T, Byrne E, Mcdonnell J. 2014. Recognizing rhetoric in
health care policy analysis. Journal of Health Services Research 13: 40–6.
Sabatier PA. 1987. Knowledge, policy-oriented learning, and policy change an
advocacy coalition framework. Science Communication 8: 649–92.
Schieber G, Cashin C, Saleh K, Lavado R. 2012. Health Financing in Ghana.
Washington, DC: World Bank Publications.
Schneider P, Hanson K. 2007. The impact of micro health insurance on
Rwandan health centre costs. Health Policy and Planning 22: 40–8.
Spaan E, Mathijssen J, Tromp N, McBain F, Have AT, Baltussen R. 2012. The
impact of health insurance in Africa and Asia: a systematic review. Bullentin
of the World Health Organisation 90: 685–92.
Sun J, Kang J, Qu Q et al. 2014. Did capitation payment reform make a difference in Chinese rural primary health care? Healthcare in Low-Resource
Settings 2: 9–13.
Tangcharoensathien V, Limwattananon S, Patcharanarumol W,
Thammatacharee J, Jongudomsuk P, Sirilak S. 2015. Achieving universal
health coverage goals in Thailand: the vital role of strategic purchasing.
Health Policy and Planning 30: 1152–61.
Walt G, Gilson L. 1994. Reforming the health sector in developing countries:
the central role of policy analysis. Health Policy and Planning 9: 353–70.
WHO. 2005. Fifty-eight World Health Assembly - Resolutions and Decisions.
Geneva: World Health Organisation, WHA58.33.
WHO. 2014. Universal Health Coverage (UHC): WHO Fact Sheet No. 395.
WHO Media Centre.
WHO. 2015. From MDGs to SDGs: A New Era for Global Public Health
2016-2030. Geneva: WHO.