Provider Based Capitation Payment (PBCP) System for UHC

The best healthcare financing model remains a priority if nations are to achieve Universal Health Coverage within the stipulated timeframes; best in terms of affordability, accessibility, and sustainability across the entire population. To attain UHC, one has to consider the macro-economic, socio-cultural, and political context of each country so as to prioritize needs and intervention processes. Though there are some basic commons, it is perceived that each country must develop a system that works for it and many have borrowed diverse aspects from different countries and they are working.

Jayesh Saini, an entrepreneur, believes that for any plan to work, one must remember that utilization of health care services depends on the affordability of the services, which in turn determines the survival of the health facility. He says that policies can be developed even by providers against which they provide the needed services but if the affordability is not put in the mix of things, we can end up having good facilities without clients. He also points out that another critical consideration for governments and especially for growing economies is the payments to service providers for sustainability. He says that as national governments set up provider-based capitation payments, they must put into consideration factors such as the running costs of those providers, levels of services being offered, or what it takes to have a facility in a specific place. He says the computations are not as easy as deciding to issue a blanket payment amount to all service providers. 

For the private investor especially, a blanket payment amount would work well if they were guaranteed a specific population. Working on economies of scale and the probability of visits by that population, where there is no adverse selection, a provider can be able to project sustainability. This is especially important for countries like Kenya which has made it compulsory for all citizens to be on the government’s NHIF cover. Considering the economic state of the majority of the population, many will not afford to have both private and public insurance and will stick to the compulsory one that has penalties. This may mean that the generally better paying private insurers will have fewer people to send to the facilities, with anticipated reduced incomes for providers. This provider-based capitation payment may be a topic that needs further discussions and deliberation. Especially important at this time when the rollout is just starting so that the issue of whether it is provider-based capitation or specific package-based capitation payments to be used. The packages must be so clearly defined and systems set up to monitor claims so that the NHIF does not end up paying more than one for the same service or denying payments for services that would appear as overlaps and yet from a medical point of view are not.