روش های پرداخت ارائه دهنده و انگیزش کارکنان بهداشتی در بیمه بهداشت و درمان مبتنی بر جامعه: مطالعه به روش مخلوط

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.

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 and 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 and 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 and 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 and 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 and 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).

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 included in the CBHI payment method), constituted a significant loss in revenue for the health facility and the workers employed there. The payment method led to a reduction in the level of bonuses paid to workers at the end of each quarter. These unintended consequences resulted in substantial resistance to the intervention among health workers. In turn, these intermediate outcomes led to low patient satisfaction and retention, resulting in CBHI performance outcomes such as limited coverage, low levels of risk pooling and financial instability. Resource allocation and purchasing procedures in health care provision have important implications for cost, access, quality, and consumer satisfaction (Roberts et al., 2008). In this study, we confirm that within the context of community-based health insurance, the method and level of provider payment directly affects health worker satisfaction and motivation. In the particular case of Nouna, the CBHI provider payment method was a substantial source of tension between competing demands placed on health workers, leading to role strain. It will be important to examine whether this phenomenon can also be identified in other settings – health workers experience increased role strain when health care payers, through changes in provider payment systems, incentivize particular behaviors that the health workers view as competing with more legitimate demands by their patients, their colleagues and health facilities, and the community in general. Based on empirical evidence in other settings, health workers' subjective experience of role strain affects objective outcomes in health systems, such as health worker performance and job retention. Health policy makers thus should work to reduce role strain, e.g., through communication and coordination of policy initiatives by the diverse actors in health systems. Our study provides further, specific evidence to support the general assertion that health worker backing is critical for the success of CBHI (Criel et al., 2005). We identify several attributes of the provider payment system that significantly affected the job satisfaction of health workers contracted by the scheme, specifically reimbursement of service fees and the level of capitation payment. We also show how the payment method affected CBHI outcomes such as the quality of care and CBHI coverage. Based on our results, it is likely that health worker satisfaction can be improved by revising the CBHI payment method, while at the same time financially motivating health workers to increase efforts to promote and support the scheme through results-oriented financing models such as Performance Based Financing.