Issahaku et al. Health Research Policy and Systems (2021) 19:145 https://doi.org/10.1186/s12961-021-00794-y RESEARCH Open Access Is value-based payment for healthcare feasible under Ghana’s National Health Insurance Scheme? Yussif Issahaku1,2, Andrea Thoumi3,4, Gilbert Abotisem Abiiro5, Osondu Ogbouji2,4 and Justice Nonvignon1* Abstract Background: Effective payment mechanisms for healthcare are critical to the quality of care and the efficiency and responsiveness of health systems to meet specific population health needs. Since its inception, Ghana’s National Health Insurance Scheme (NHIS) has adopted fee-for-service, diagnostic-related groups and capitation methods, which have contributed to provider reimbursement delays, rising costs and poor quality of care rendered to the scheme’s clients. The aim of this study was to explore stakeholder perceptions of the feasibility of value-based pay- ment (VBP) for healthcare in Ghana. Value-based payment refers to a system whereby healthcare providers are paid for the value of services rendered to patients instead of the volume of services. Methods: This study employed a cross-sectional qualitative design. National-level stakeholders were purposively selected for in-depth interviews. The participants included policy-makers (n = 4), implementers (n = 5), public health insurers (n = 3), public and private healthcare providers (n = 7) and civil society organization officers (n = 1). Interviews were audio-recorded and transcribed. Data analysis was performed using both deductive and inductive thematic analysis. The data were analysed using QSR NVivo 12 software. Results: Generally, participants perceived VBP to be feasible if certain supporting systems were in place and potential implementation constraints were addressed. Although the concept of VBP was widely accepted, study participants reported that efficient resource management, provider motivation incentives and community empowerment were required to align VBP to the Ghanaian context. Weak electronic information systems and underdeveloped healthcare infrastructure were seen as challenges to the integration of VBP into the Ghanaian health system. Therefore, improve- ment of existing systems beyond healthcare, including public education, politics, data, finance, regulation, planning, infrastructure and stakeholder attitudes towards VBP, will affect the overall feasibility of VBP in Ghana. Conclusion: Value-based payment could be a feasible policy option for the NHIS in Ghana if potential implementa- tion challenges such as limited financial and human resources and underdeveloped health system infrastructure are addressed. Governmental support and provider capacity-building are therefore essential for VBP implementation in Ghana. Future feasibility and acceptability studies will need to consider community and patient perspectives. Keywords: Feasibility, Ghana, Health financing, National health insurance, Value-based payment Background Globally, increasing healthcare costs have resulted in healthcare expenditures that exceed gross domestic *Correspondence: jnonvignon@ug.edu.gh 1 Department of Health Policy, Planning and Management, School product (GDP) growth rates [1, 2] and often led to cat- of Public Health, University of Ghana, Legon, Ghana astrophic spending by households. In many low-and Full list of author information is available at the end of the article middle-income countries (LMICs), rising healthcare © The Author(s) 2021. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Issahaku et al. Health Research Policy and Systems (2021) 19:145 Page 2 of 14 costs have occurred despite low total healthcare spend- funds spent in the healthcare market, including value- ing measured as a percentage of GDP and as per capita based payment (VBP) models [14, 15]. spending. For example, increasing healthcare costs Growing global interest in VBP is due to a collective in Ghana are due to increases in both demand (e.g. call for better healthcare for individuals and popula- increased coverage of the population and services pro- tions, reduction in the cost of healthcare, and general vided through the National Health Insurance Scheme improvement in population health [16]. VBP methods [NHIS]) and supply (e.g. higher cost of medical technolo- aim to improve healthcare quality while minimizing gies) to meet population health needs. Ghana’s develop- total cost by linking financial incentives to the value of ment over the past two decades has improved population health outcomes rather than volume [17]. VBP methods health including increased life expectancy and reduced are designed to create new care delivery models centred infant mortality [3–5]. These health improvements, along on patient and population health outcomes [18]. Value with other development factors such as increased house- is explained as improved health outcome that yields hold spending, have (1) increased the demand for health maximum health benefit at a minimum cost—through services and (2) created an epidemiological transition. delivery processes that offer the best patient experience The central government, healthcare providers and users, and minimize clinical errors [19]. Furthermore, value is and other stakeholders in Ghana have identified rising conceptualized as multifaceted and encompasses not healthcare costs as a priority health financing area to only high quality of care at the lowest possible cost, but address in the country [6]. also efficiency in cooperation, innovativeness and health Ghana is one of a few countries in sub-Saharan Africa promotion [20]. Yet, while many health systems have (SSA) that have implemented a social health insurance implemented VBP models as a health financing strat- model, with the aim of removing cost as a barrier to egy, concerns about healthcare costs, efficiency, quality, quality healthcare. By increasing affordability, the intro- affordability and equity abound [21]. duction of the Ghana NHIS in 2004 has significantly VBP models vary in complexity and intended effects increased healthcare utilization and reduced health dis- on quality, cost and efficiency. Models range from pay- parities in access among Ghanaians in the past decade for-performance (P4P) to bundled payments to shared [7]. Since the implementation of the scheme, the National savings and shared risk models [22]. In a P4P system, Health Insurance Authority (NHIA) has employed differ- providers receive financial bonuses for meeting specific ent payment models, including fee-for-service (FFS) and care quality metrics and cost targets [22]. Bonuses have diagnosis-related grouping (DRG), and piloted the capi- not always proven to be sufficient in driving the desired tation method [8, 9]. However, these payment methods change in provider practice or health outcomes [23]. have not been able to comprehensively address the chal- Bundled payments involve fixed, predetermined fees paid lenges of the rising cost of healthcare, delays in reimburs- to providers to perform all the associated services of a ing providers and, more importantly, the poor quality of given procedure, rather than paying for each service sep- healthcare received by the NHIS clients [8, 9]. Problems arately [24, 25]. Thus, providers are rewarded financially associated with these predominant payment methods for performing procedures in cost-efficient and effective coupled with resource constraints, socioeconomic fac- ways, while avoiding unnecessary procedures and dupli- tors and lapses in health policy implementation and man- cation of services [24]. Under the shared savings model, agement have led to notably compromised quality of care payers set a budget for care delivery costs as a ceiling for that clients receive [10]. total costs of providers, and those providers whose total The performance of any healthcare financing system costs fall below the budget share in the savings. With the depends on the payment and care delivery mechanisms shared risk model, providers are still able to share in any adopted. Predominant payment mechanisms that are recognized savings but are also expected to pay for costs used globally include FFS, DRG, capitation and mixed that exceed the care delivery costs set by the payer [19]. payment methods [11]. Although these payment meth- Although studies have been conducted in the area of ods have helped shape health financing in many coun- health financing in Ghana, particularly regarding enrol- tries, poorer health outcomes and quality of care are ment and equity [26, 27], there is paucity of research partly attributed to the methods by which healthcare exploring the use of VBP for healthcare as a channel to providers are reimbursed for their services delivered [12]. complement coverage improvements with care delivery For LMICs, health financing systems are one barrier to models that shift the focus of care to overall population countries’ pursuit of primary healthcare (PHC) for all health. In the absence of a specific VBP model currently and attaining universal health coverage (UHC) [13]. In implemented in Ghana, it is important to explore VBP recent years, developed countries have been employing in its generic sense to identify the general factors that new payment strategies that seek to promote value for can facilitate or impede the design and implementation I ssahaku et al. Health Research Policy and Systems (2021) 19:145 Page 3 of 14 of a potential VBP system in the country. The Ghanaian appropriateness, satisfaction and perceived positive or environmental context (structure, political, legal, socio- negative effects of VBP on Ghana’s health system. (2) economic, market conditions and regulatory factors), Practicality refers to the extent to which VBP can be car- provider capacity (financial, essential staff, infrastruc- ried out in Ghana using existing means, resources and ture), provider and payer alignment systems, and health circumstances without outside intervention. The effects information systems are essential determinants of the of VBP on target stakeholders and their ability to carry appropriateness of VBP in Ghana [17]. out intervention activities, as well as cost analysis, were While many countries have designed and implemented the outcomes of interest. (3) Integration refers to the a wide range of specific healthcare programs that fit into extent to which VBP can be integrated within the existing VBP models, challenges in implementing any of the many Ghanaian health system. Here, we assessed the perceived VBP models vary by country context [13–15]. In Ghana, fit with infrastructure, perceived sustainability, and cost value is a channel that can encourage new care delivery to policy and implementation bodies. (4) Implementation models or payment for nonclinical providers (like com- refers to the extent to which the policy can be success- munity health workers) to extend the reach of the health fully implemented. Here, we focused on the amount and system to rural or low-resource areas. In turn, VBP can types of resources needed to implement it, factors affect- serve as an alternative provider payment mechanism ing implementation, efficiency, speed or quality of imple- that Ghana considers as it seeks to extend PHC and meet mentation, degree of execution, and success or failure of UHC goals. This study therefore explored stakeholder execution. The assessment of feasibility based on these perceptions of the feasibility of introducing the general four areas helped to determine whether VBP is feasible in concept of VBP as one of the alternative provider pay- Ghana [28]. We investigated only these four focus areas ment mechanisms that the NHIS could consider to pay in this study because VBP has never been implemented for health services. Specifically, this study aimed at pro- in Ghana. Thus, the demand (data on estimated or actual viding the first step towards understanding the feasibility use of selected intervention activities in a defined inter- and buy-in among policy-makers, purchasers and pro- vention population or setting), expansion (the potential viders. However, given the mixed evidence of the perfor- success of an already successful intervention with a dif- mance of VBP models (e.g. can exacerbate inequities), the ferent population or setting) and limited-efficacy testing authors have not taken the strong position that VBP is (testing of an intervention in a limited way, with interme- superior to other provider payment mechanisms or that diate rather than final outcomes) aspects were not appli- it is the best option for payment reform in Ghana. As cable in this study. the NHIS does not pay for health promotion and disease prevention, the authors did not explore VBP as a broader Study design and sampling payment mechanism for public health interventions. A cross-sectional qualitative design was used for this study, where data collection took place in Accra over Methods a period of 2 months. The data were collected from a Conceptual framework for assessing feasibility purposive sample of health system stakeholders at the Bowen et  al. [28] identified the following focus areas of national level to explore their perspectives about the feasibility: acceptability, demand, practicality, integra- feasibility of VBP for healthcare under the NHIS and tion, implementation, adaption, expansion and limited- the perceived facilitators and barriers vis-à-vis its imple- efficacy testing. These aspects are crucial in investigating mentation. We purposively sampled national-level health the likelihood of effective implementation of an interven- policy-makers, NHIS staff, implementers, practitioners tion. The authors noted that the outcome of a feasibility (physicians, midwives, nurses) and civil society organi- study is used to determine whether a programme, ser- zation (CSO) officers. We selected these stakeholders vice, policy or product is appropriate for further testing. because of their direct knowledge and understanding Country ownership and multi-stakeholder collaboration of health financing, provider payment mechanisms (e.g. are vital components of any health reform effort. While VBP models) and the current health financing schemes VBP to date has largely been piloted in health insurance in Ghana. Hence these stakeholders were recruited to claims, there is a potential to use VBP to meet current ensure data relevance. Patients and community residents health commitments. were excluded from this exploratory study because VBP The present study focused on four areas of feasibil- has never been implemented in Ghana. Therefore, these ity. (1) Acceptability refers to the extent to which VBP stakeholders would have less exposure to the concept of was judged as suitable or attractive to specific stake- VBP and would not meet the criteria for subject mat- holders. The sample outcomes of interest included par- ter experts within our purposive sampling criteria [29]. ticipants’ intent to support implementation, perceived Resource limitations for this study was another reason Issahaku et al. Health Research Policy and Systems (2021) 19:145 Page 4 of 14 for community-level exclusion. Permission and recom- was applied to all the transcripts. The transcripts were mendation of potential participants were sought from coded by two different people to identify themes under heads of target institutions with attachments including each feasibility focus area. Out of the total transcripts, an ethical clearance letter, consent forms and study pro- four transcripts were randomly selected to be coded posal. Recommended persons were contacted by phone independently by two people to establish inter-coder for further permission and arrangement of interviews. trustworthiness. All initial disagreements that were A total of 20 health system stakeholders were identi- identified between the two people were resolved using a fied and interviewed, including policy-makers from the consensus approach. Data analysis was performed using health ministry (n = 4), implementers from the GHS both deductive and inductive thematic analysis methods Head Office (n = 5), frontline public and private pro- [31, 32]. In order to become familiar with the data, the viders (n = 7) including medical doctors, midwives and transcripts were first read repeatedly while critically tak- nurses, insurers from NHIS (n = 3) and CSO members ing note of patterns within the data. Similar data types (n = 1). The criteria for inclusion were as follows: inter- were grouped into initial categories and notes were also viewees (1) understood English and (2) had worked with prepared from this process. There was a critical exami- their institutions or similar ones for at least 3 years, to nation of the initial categories to ensure that each cat- ensure that participants had some experience relevant to egory represented participant responses before labelling the study. Those who could not provide vital information these categories as codes. The themes interpreted by the to the study due to ill health or for other reasons were researchers from the codes were used to assess the feasi- excluded. bility of VBP for healthcare in Ghana. Data collection method and tool Results Individual in-depth interviews (IDIs) were conducted Sociodemographic characteristics of the study participants with participants using a semi-structured interview guide A total of 20 individuals participated in the study, includ- that focused on the four feasibility focus areas and gen- ing four policy-makers, five implementers, seven provid- eral facilitating and constraining factors of VBP. The data ers, three insurers and one CSO member. All the study collection tool was designed by the authors based on the participants had over 3 years of working experience, with literature to cover the generic factors that affect VBP the majority of participants in the 3–10-year work expe- models including the environmental context, provider rience category. Table 1 provides a summary of additional capacity, provider and payer alignment systems, and data sociodemographic characteristics of the study partici- infrastructure [17]. The data collection tool covered key pants, including sex and age. areas including participants’ reaction to VBP and the extent to which it could be adopted in Ghana, how VBP fit with Ghana’s health system, and the perceived ease or Understanding of VBP difficulty in its implementation. Because of the COVID- The responses from the study participants revealed that 19 pandemic, the interviews were conducted mainly by almost all participants understood VBP to mean pay- telephone and lasted between 20 and 40  minutes with ing for the value of service outcomes instead of paying each participant. Interviews were audio-recorded follow- for volumes, as explained in the literature [17, 20, 33]. ing participant consent. Data collection took place from Participants viewed VBP as a strategy that could ensure August 2020 to September 2020. The data collection provider accountability for healthcare quality and costs, instrument was pretested to identify lapses, and the nec- improve health system efficiency and effectiveness, and essary updates were made before beginning stakeholder ensure health system responsiveness to the needs and interviews. All data were collected by the first author, expectations of healthcare seekers. The following quotes mostly by telephone interviews. The interviews ended illustrate participants’ understanding of VBP. when saturation of data was reached at n = 20, thus when Value-based payment is basically the concept where no new information was obtained from any additional the purchaser of the healthcare, I mean, say the gov- participant sampled for the study [30]. ernment, employer, consumer, and where you have the payers either public or private individuals, holds Data analysis the healthcare provider accountable for both quality All interviews were audio-recorded and transcribed and cost of care.. (Implementer #2, IDI) verbatim into Microsoft Word 2013 by the lead author Patients seek healthcare and expect to derive some with the assistance of an experienced transcriptionist. value from the services rendered by healthcare pro- The data were then processed and analysed using QSR viders in terms of satisfaction of their health needs. NVivo 12 software. A phrase-level analytical approach And therefore within that context they must have Issahaku et al. Health Research Policy and Systems (2021) 19:145 Page 5 of 14 Table 1 Sociodemographic characteristics of study participants Characteristic Number of participants Policy-makers Implementers Providers Insurers CSO (n = 4) (n = 5) (n = 7) (n = 3) (n = 1) Sex Male 4 5 6 2 1 Female 0 0 1 1 0 Age (years) 30–39 1 0 3 0 1 40–49 3 5 4 3 0 50+ 0 0 0 0 0 Length of service (years) 3–10 3 2 5 1 1 10–20 1 3 2 2 0 the power to hold the healthcare providers account- I think VBP will be useful. In fact, it is very essential able to them—that they do the right thing. Thus, pro- in the case of Ghana’s national health insurance and viding quality services in a manner that avoids long that is why somehow, the NHIA has been doing that patient waiting time and negligence and all that. So by doing evaluation at the healthcare institutions to when providers are paid based on patient health see if things are in order before engaging providers. outcomes or for meeting some expectations, then the And that is how come sometimes when the bills are payer is actually doing VBP. (Policy-maker #4, IDI) submitted, healthcare providers are “punished” by reduction from the claims they submitted. (Imple- menter #5, IDI) Perceptions of feasibility of VBP Acceptability The following subthemes were identified by participants Perceived impact of VBP on health system in relation to the facilitators of and barriers to acceptabil- All participants reported that VBP was an encouraging ity of VBP in Ghana. concept due to its potential advantages in the delivery of health services in Ghana. For instance, most participants Appropriateness of VBP from each health system stakeholder category thought All participants considered VBP a relevant concept that that introducing VBP under the NHIS had the potential needs to be discussed and explored in the Ghanaian to reduce cost and waste, improve healthcare quality, health policy context. Participants were cognizant of increase client satisfaction and bring equity to the pro- the impact that the current payment methods used by vision of services in the healthcare system. Participants the NHIA have on the quality of healthcare that provid- emphasized that efficiency and effectiveness in the health ers render to clients. Participants noted that the cost and system can only be achieved if VBP models are effectively quality of healthcare in Ghana need to be addressed and implemented. The following quotes highlight how VBP that paying for value is a positive direction. Further, par- would impact healthcare in Ghana if implemented: ticipants articulated the importance of increasing aware- ness of VBP among the public to facilitate action. The Well,… to be honest, the current system favours the following quotes relate to the theme of appropriateness: hospitals or the healthcare providers, in that if a patient comes to my hospital, anytime I do labora- You can’t really extract the value of services pro- tory test I get money for it. Then I will do more lab vided under this current system. So this VBP under test to get more money. But with the VBP, that one the NHIA would have been very appropriate and you are not looking at the number of test you did helpful. The NHIA will actually know the value of but rather how better is the patient at the end of the services rendered by healthcare providers and not day—has the patient recovered? What is the out- just paying for volumes of services given to clients. So come of all the services you have provided? Based I believe that it will be of essence to try other pay- on these that you are paid. I don’t know too much ment mechanisms. (Policy-maker #1, IDI) about the financial implication of VBP; however, it Issahaku et al. Health Research Policy and Systems (2021) 19:145 Page 6 of 14 will benefit patients more than the provider depend- …yes, yes because it is good, because it sustains the ing on who bears which quantum of the financial scheme, it will reduce wastage, and Ghanaians will burden. Thus, the patient might pay less premium save money for a lot of things. So yes, I will support for the insurance, because for any visit to a health it. (Insurer #1, IDI) facility, everything is geared toward what would I will surely support it..., you see … change, they say, make the patient better and not unnecessary services is not easy. But with sensitization and education to escalate cost for the NHIA to pay. So VBP will people will get to understand the importance of VBP. have more benefits to patients, and I think that is (Provider #6, IDI) the most important thing. And as a country in gen- Personally I would support VBP, and I think that it eral, VBP will have a positive impact on our devel- is a reform that will restructure our insurance sys- opment, especially in the health sector, and it might tem. It will streamline our payment mechanisms also have some form of financial stability for the hos- toward bringing the very best of care to health ser- pitals, as payment of claims will no long delay like vice users. (Policy-maker #1, IDI) what we are experiencing now. (Provider #5, IDI) If VBP is well structured, patients will definitely Another participant mentioned that VBP would have accept it. a positive impact on Ghana’s quest towards attaining an One participant noted their intent to support efforts to equitable healthcare system. implement VBP as long as there were no negative finan- In my personal view, this form of payment… as I cial implications for patients. said in my earlier submission… will bring some form Sure! I will support it because it is going to improve of equality in providing healthcare. You don’t need the quality of healthcare in Ghana. So if the govern- to be rich to get proper healthcare. You don’t need ment or the NHIA will be able and willing to pay to be poor to get the lowest healthcare. Once provid- providers for the desired service outcomes, why not? ers are paid for value it is going to be a standardized I will surely support it. But the possibility is also that something. So for me I believe that form of payment VBP might lead to increase in premiums, and if that will bring standardization across board. (Imple- is going to be borne by consumers I will not support menter #1, IDI) it, because in that case most citizens will not be able Some participants also perceived VBP as a means to to subscribe with the NHIS. (Policy-maker #3, IDI) sustaining the NHIS, as in the quotes below: …if it is brought into our health system it will be Perceived acceptability challenges very good and suitable. I believe that some of these Participants mentioned some factors that could limit monies paid to providers by the NHIA right now will the acceptability of VBP including political interference, cut down, and secondly, it will put pressure on the resistance from healthcare providers and poor knowl- service providers to provide the best form of services edge of the policy. available. It is very difficult to determine the quality If prior measures are not put in place for a surety, of services in the current payment mechanisms. So I healthcare providers will reject VBP. But for cer- believe that VBP will sustain the NHIS and that will tainty government and other health insurance be very helpful in our health system. (Policy-maker authorities will welcome VBP. But for providers #1, IDI) there will be a problem unless we put effective meas- It will be appropriate because it will lead to some ures prior to its implementation. (Provider #4, IDI) sort of value for money. Because if there is a certain So there are some other political underpinnings accountability and some transparency, the providers regarding some of these things. So partisan poli- are likely to give what the people need. (Provider #4, tics will be another thing that will have some effect IDI) on VBP implementation. Yes, so where they actu- ally don’t have consensus on some of these issues, it becomes a challenge to implement. (Implementer #2, Participant support for VBP IDI) When participants were asked about their intention to Political agendas will also hinder VBP implemen- support VBP implementation if it is proposed in Ghana, tation. You know, Ghana, here everything is about all participants said they would support it. The partici- partisan politics. Every political party will have a pants declared their intentions to support implementa- different view or interest with regards to this VBP tion of VBP in Ghana as follows: method, and that could be a hindrance to this pay- I ssahaku et al. Health Research Policy and Systems (2021) 19:145 Page 7 of 14 ment reform. (Policy-maker #3, IDI) efficient services since their rewards would be based on So some of the things we can look at is proper edu- the value of service outcomes. cation, and getting all the actors involved to under- As two policy-makers noted: stand the VBP concept. (Implementer #2, IDI) In the short term, it will make the government unpopular because of the inherent challenges in our health system, but it will inure to the benefit of the Practicality government in the long term because the systemic Three subthemes were identified under this theme: problems would have been identified and addressed resource management, motivation and empowerment. to make the system function well. It will benefit the insurers because claims would be subjected to seri- Resource management ous scrutiny in terms of quality of services provided to clients by providers. The providers will be efficient With proper resource mobilization and alloca- in the provision of quality services because they do tion—including financial and material resources, not want to make losses or suffer any penalty for pro- I think Ghana should be able to implement VBP viding poor services. (Policy-maker #2, IDI) successfully without much problems. There must be I think VBP will really help health service delivery in adequate, regular and evenly distribution of health Ghana. You know, when the service providers real- resources across the country. (Implementer #5, IDI) ize that they are paid more when they offer quality Another thing is to have a better or adequate fund- services, then their efficiency and effectiveness will ing—whichever way we have to go to get a good become higher as compared to their current per- funding to undertake that…that would be fine. Once formance under the payment mechanisms we have there is funds I think VBP can be done. (Imple- now. (Policy-maker #3, IDI) menter #2, IDI) Once we are going to look at outcomes and results, Similar statements were made by other participants as then it means that we are going to pay realistic tar- follows: iffs and so budget or finance should be properly allo- Generally, in my view… it will put the healthcare cated, and all these things will come to play at the providers on their toes. It will serve as a check and end the day. (Insurer #3, IDI) they will have to do quality work, I mean, to merit the payment that they are going to get. And I think in that line everybody will take it serious. Once pay- Motivation ment is based on performance and then they can be Participants indicated that paying providers based on appraised based on that sort of thing, they will sit merit, providing support for healthcare providers to be up. (Implementer #3, IDI) able to carry out implementation activities, and paying It will have a great impact on our health system—a claims regularly were incentives for the providers to carry positive one of course. In terms of providers, you will out their roles effectively. get to know the serious ones—those who are ready to The service providers are in to make money, espe- provide effective and effective services. (Provider #4, cially the private providers…so I think that if they IDI) have actually given them a proposal that is attrac- However, one of the insurers had a different opinion tive, at least something to keep them in business. But about the likely behaviour of providers if they were going you go and do business and it’s a total lost—I think to be paid on the basis of service outcomes. providers would not be interested because for the national health insurance a lot of people are break- …In that case, providers will try to decrease the ing off now because government is owing them a lot waste they won’t be paid for. They will find ille- of money. (Provider #2, IDI) gal practices to make sure that the wastage is still catered for, like copayment, like abstract payment When a question was asked about the perceived posi- for medicine or certain services that are covered. tive or negative effects that VBP would have on the major That normally happens. So when you introduce VBP, health system actors (e.g. the government, the NHIA and on the flip side you’re likely to get illegal practices those who offer health services to patients), participants that if you don’t control it well, can actually reduce indicated that VBP could reduce public sector cost and the confidence that the people have in the scheme. waste. Participants also noted that healthcare providers (Insurer #1, IDI) would be encouraged and motivated to offer effective and Issahaku et al. Health Research Policy and Systems (2021) 19:145 Page 8 of 14 Empowerment VBP will be sustainable to a higher level. However, Generally, participants talked about the potential of a when you look at our system in terms of technology VBP system to increase patients’ awareness of their rights and tools, it seems we are lacking. So, for instance, and entitlements under the NHIS. Again, some partici- if I go to Legon hospital and I have been referred to pants believed that paying for value could reduce public Korle-Bu teaching hospital, there wouldn’t be any sector cost burden by focusing on providers of higher- electronic sharing of my details to the referral hospi- quality health services, which could empower providers tal from the previous hospital visited. There should in terms of improving their liquidity. be a system where there is coordination such that Then again, the providers are now going to be on anytime and anywhere you login with a patient ID their toes because if the policy is well communicated, number you will have access to the medical history the people will get to know their rights and how to of that patient for review. So we have to reshape our hold the providers accountable for the kind of ser- data system in order to have an effective implemen- vices they provide. So the providers would do bet- tation of VBP. (Provider #4, IDI) ter, as they’re aware that this is what they must do, …you know, we are in the 21st century—data man- and if they don’t do it consumers will take them on, agement and sharing should not be a problem, but which affects their reimbursement. (Implementer #5, it is a problem because we have not moved to that IDI) level as a country. And so I feel that it is going to be I think the government and the insurers will get a big challenge because we don’t have the requisite value for money. The scheme will not be overbur- data systems. (Policy-maker #1, IDI) dened. There will be money in the system to pay for You see, …there is more to be done about our data healthcare when the excesses and points of wast- and information systems for VBP to work well. (Pro- ages are abolished. And I think for the providers it vider #5, IDI) will help them because, I mean, they’re in business …also, we must have a strong database to help with to work and make profits. So if there is a secure, reli- accurate projections of the people to cover and even able system that will ensure regular source of pay- the funds inflow, which is currently a challenge. ment, then providers will have a good cash flow to be (Provider #1, IDI) able to operate and deliver better health services to In contrast, other participants mentioned the strides the people. (Provider #1, IDI) Ghana has made in digitalization in recent years and Another participant noted a productivity point of view: were optimistic that data linkage and sharing would not be a significant implementation barrier. One service pro- So if patients are treated better as everything is vider explained: geared toward quality care and not just paying for numbers, then we will have less morbidity, people …like I said, I have never used my national health will be healthy to work, and this would reflect in insurance before, and another thing that I was their productivity. Also, the general health of the always worried about was renewal of my NHIS card. population will improve. So I think VBP will have Because those days you had to go to their office and a lot of benefits. I wouldn’t hesitate to support its queue. It was stressful. But since the introduction of implementation in Ghana. (Provider #5, IDI) this mobile renewal system, you just have to dial a number, and once you have money in your mobile money account, you can just renew your card within seconds. Aha! So I think there will not be so much Integration problem with data—even if there will be issues, they Data and data systems would be minor ones. (Provider #2, IDI) The perception among most participants was that the When it comes to the data, what would have made data system in Ghana was not suitable for implementa- it more qualitative may be lacking. And then, you tion of VBP. know, the part of the world of our system, even if we go cloud, it is still going to face problems because the There is still a gap in terms of data-sharing because network system is not good. I think data infrastruc- most of our facilities still submit even health insur- ture is going to be a problem. (Implementer #4, IDI) ance claims manually. So until we all go probably electronic with all the facilities, then that better link- A similar opinion was shared by another participant: age can be seen, but for now it is a big challenge, a Generally, there is a movement towards this sort of gap. (Implementer #2, IDI) cashless system, digitalization and all these things. I ssahaku et al. Health Research Policy and Systems (2021) 19:145 Page 9 of 14 Now, through these multitudes of identities— port externally to go that way. (Implementer #2, IDI) national identity card, health insurance, voter’s ID card… we can get a very good database to be able to implement this. (Policy-maker #4, IDI) Underdeveloped infrastructureParticipants pointed out some factors that could deter- mine the level of integration of VBP with the existing Sustainability system: There were varied opinions regarding the sustainabil- ity of VBP in Ghana if implemented. Most participants Our healthcare infrastructure is not yet developed were optimistic about the sustainability of VBP for health to support the implementation of VBP in Ghana. financing in Ghana as long as certain conditions were So unless the issues of infrastructure is addressed, I met. These conditions included reliable funding source, think it will be a barrier. (Provider #5, IDI) general acceptability of VBP, proper planning and execu- …and also, underdeveloped hospitals, for example, tion of the policy, and the cost and waste reduction ben- most of our emergency rooms in the GHS are one- efits of VBP. room facilities for both sexes. And sometimes the same toilet is used by both sexes, they queue to go Inasmuch as VBP is a good concept, okay, I think to toilet—no privacy. So you say you are paying for that it would be sustainable. (Implementer #2, IDI) value, but it is not the duty of the healthcare provid- …so I think it will be very sustainable, but maybe in ers to expand the facility, especially in the case of the beginning we have to do a very efficient course public hospitals. It is the government’s responsibil- assessment sort of looking at ways of financing before ity to provide those facilities in this case…. (Imple- we hit the ground to be sure that we will not run out menter #5, IDI) of funds in the middle of it. (Provider #1, IDI) I already stated that if VBP is a top priority of gov- ernment, sustainability would not be a problem. Implementation (Policy-maker #1, IDI) Participants were asked to share their views on how they For VBP to be sustainable in Ghana, I think that it perceived the capacity of each major health system actor should be implemented in a way that it is a win–win (e.g. providers, government and NHIA) to support VBP from the very beginning for all the parties involved: implementation if proposed. Participants focused more the insurer, the provider and the government. With on the capacity of the service providers and the govern- that you’d get all the parties putting up their best… ment, since both provider capacity and government pol- to make sure that they benefit from the policy. So the icy have a direct influence on the feasibility of VBP. Most providers and insurers will do their best and the gov- participants perceived the capacity of government to be ernment as well will provide a conducive environ- higher and that VBP could be feasible in Ghana. Par- ment for the model to flourish. (Insurer #2, IDI) ticipants indicated that the government could provide human resources and equipment to improve provider A few participants thought that VBP was not sustain- capacity. able for certain reasons as cited below. The sustainability can get to essential players in the Government buy‑in political space and this may be a challenge. Any gov- With regards to the capacity of the major actors, ernment that comes in and decides to pay less atten- let me talk on the government side only, because we tion to it may be a challenge. (CSO #1, IDI) are into policy-making. The NHIA people can help Sustainability is the problem…that will be a chal- you with the rest. For the government side, it is the lenge. As nation we are likely to fail when it comes to motive, you know…every move is driven by what is sustainability of policies of this kind. You know, eve- called a political ambition of the government. So if it rything revolves around financing, and as a country, is an ambition of the government, then resources can that has been the major challenge for us—the ability be allocated for the implementation of this payment to raise the needed capital. And even with the cur- reform. So if VBP is something that the government rent health insurance system that we are operating, wants to implement, it is capable of doing it. But if financing has been the major challenge. We still face it’s not part of government top priorities, then imple- problems of unpaid claims by the government or mentation will be an issue. So VBP has to be bought the authority involved, but VBP will require more. by the health minister and the government; then, of So sustainability will be an issue. Unless, otherwise, course, getting resources to implement it will be very they have some kind of extra funding and some sup- simple. (Policy-maker #1, IDI) Issahaku et al. Health Research Policy and Systems (2021) 19:145 Page 10 of 14 Government is well structured and has the politi- are government-owned and are mostly underdevel- cal willpower with them. Government is well struc- oped or under-resourced. And even the private facil- tured to do it, but whether or not VBP will find its ities, not all of them have what it takes to provide the way onto government policy agenda is also a differ- kind of services that are expected in a VBP system, ent issue. Because I have not heard any discourse and don’t forget that funding is always a problem in in the public domain that will make VBP clamour Africa, not excluding Ghana. So I think serious work to be placed on the government agenda, and that is really need to be done before we can implement VBP. where policy-making starts from. As for the provid- (Provider #5, IDI) ers, they may need to be equipped well in terms of The lack of proper funding or adequate funding to both human resources and machines to be able to carry out activities will actually hamper the imple- deliver quality care to clients. (Implementer #5, IDI) mentation of VBP. (Implementer #2, IDI) We need adequate funding…we have to be sure of how to make the money, how to manage it and how Provider capacity‑building to allocate it. (Provider #6, IDI) We have the resources to implement VBP. However, Our healthcare infrastructure is not yet developed we need to create a conducive environment for the to support the implementation of VBP in Ghana. healthcare providers—that is, the health facilities, So unless the issues of infrastructure is addressed, I the kind of equipment they need and other support- think it will be a barrier. (Provider #5, IDI) ing health workers. For that to happen, the govern- ment must also provide the resources before the service providers can also provide quality care, espe- Discussion cially when it comes to the health insurance. (Pro- This was the first study to explore the feasibility of VBP vider #4, IDI) as a potential alternative provider payment mechanism …the government also has the capacity to empower for the NHIS of Ghana. The study discovered many fea- healthcare providers by, let’s say, resourcing our sibility-related issues concerning the acceptability, prac- healthcare facilities to enable them to deliver prop- ticality, integration and implementation of VBP in Ghana erly. Also, the NHIA has the capacity to put systems [28]. In general, VBP was perceived as feasible in terms of in place to monitor and track performance of service its conceptual relevance, practicality and acceptance by providers. And I think the providers too can do well key health system stakeholders. However, we discovered, in the area of capacity-building to be able to render in line with others [34–36], that many supporting sys- quality healthcare for the people. (Insurer #2, IDI) tems are needed, and current health system constraints would need to be addressed to fully establish the feasibil- ity of VBP in Ghana. Our findings on the determinants, Resource constraints including facilitators and barriers, of VBP feasibility in Some participants thought that the major health system Ghana are discussed below along our feasibility concep- actors did not have the capacity to implement VBP in tual framework of acceptability, practicality, system inte- the context of the current Ghanaian health system. Par- gration and implementation capacity. ticipants shared similar views regarding the inadequacy of health professionals, financial constraints, and inade- quate infrastructure and equipment in the current health Acceptance and feasibility system. For these reasons, participants perceived VBP as The acceptance of VBP and understanding of the impor- difficult to implement. tance of the payment method among all health system stakeholders are crucial to VBP implementation success. In Ghana here, I think the capacity is not that much, Acceptance of VBP determines the extent of contextual because when you look at the doctor–patient ratio readiness for its execution as a locally driven payment in Ghana it is worrisome. If we had enough doctors reform and fosters multi-stakeholder collaboration [17]. I would say our capacity is moderate. I think right Due to poor understanding and misconception regarding now our doctor–patient ratio in Ghana is 1:10 000+ the capitation system, acceptance of this payment model or so. And besides, we don’t have adequate health was low among providers and clients in Ghana, which facilities to contain the patients, so the capacity is adversely affected its perceived implementation feasibil- not there. (Policy-maker #3, IDI) ity [8, 37]. There was a general perception of relatively …for me, I think we are not ready for VBP. You see, low healthcare quality under the capitation method in resourcing our healthcare facilities will be a chal- the Ashanti region of Ghana where it was piloted [38– lenge. As you are aware, majority of our hospitals 40]. However, participants in our study acknowledged I ssahaku et al. Health Research Policy and Systems (2021) 19:145 Page 11 of 14 the relevance of VBP as a potential solution to addressing et al. [43], which concluded that all essential data must the cost escalation and waste that are associated with the be in electronic form and linked in order to introduce current FFS payment model. a P4P programme. Some participants also thought that Participants believed it was appropriate to introduce Ghana had made tremendous strides in the area of digi- VBP under the NHIS, as they perceived the payment talization and cashless systems, which in addition to model to be compatible with Ghana’s health system goals system flexibility will make the issue of weak data infra- and culture. Unlike the resistance to the capitation sys- structure easier to deal with. An improved electronic tem by subscribers and providers, the outcome of this information management and healthcare infrastruc- study indicates a higher potential support for VBP among ture are therefore recommended for the integration of health system stakeholders on the basis of perceived VBP and its sustainability within the Ghanaian health appropriateness and fit within the organizational objec- system. tives of the NHIS [28]. These positive findings of the Participants assumed that provider capacity could be perceived acceptability of VBP in Ghana must be viewed intensified with government support through the provi- with caution, as potential barriers to acceptability such sion of human resources and equipment. Specifically, as political interference, resistance from providers and most participants noted that provider capacity and will- poor general population knowledge of the VBP concept ingness to carry out implementation activities had a were reported by our study and others [41, 42]. In addi- strong bearing on the success of the payment reform. tion, our study focused on exploring the concept of VBP However, participants perceived the doctor–patient ratio among health system actors, and did not include com- and health equipment in Ghana as inadequate for VBP munity or patient perspectives, which would need to be implementation. Participants noted that these barriers explored in future research. could be addressed with government commitment and support. For example, all participants said there should Key facilitators and barriers regarding practicality, be initial required capital available before VBP can be integration and implementation adopted and a reliable source of funding to ensure its sus- A review of six case examples of VBP initiatives by Con- tainability. A previous study conducted in Tanzania also rad et  al. [17] in three different regions of the United identified these perceived challenges relating to weak States revealed an array of facilitators that influenced infrastructure and resource availability [44]. successful implementation. The facilitators included, but Participants thought that VBP would lower the govern- were not limited to, stakeholder consensus on the need ment’s and NHIA’s financial burden, as cost and waste to bring spending on healthcare under control; the exist- would be reduced. According to participants, a lower ence of legislative, social and regulatory conditions for financial burden could provide a source of financial reforms of payment methods; robust governance and empowerment for both payers and providers to operate action support from provider and consumer organiza- and render quality healthcare to the Ghanaian population tions, major purchasers and health plans; and the availa- in an effective and efficient manner. Theoretically, the bility of an all-payer claims database that could be linked savings generated by reducing low-value care and waste to an electronic health record system, in addition to a could be redirected to increase staffing and other essen- favourable market. These findings corroborate the find- tial medicine and equipment for provision of quality care. ings of Kruk [40], which identified three facilitators that These steps are critical for providers to align their opera- could be established at both local and regional levels to tions with any value-based care model [40]. Increasing support the success of value-based care models, and they essential staffing, medicine and equipment would have a include data standards (a common data system embraced positive effect on the development of healthcare facilities by all stakeholders in a health system), capabilities (health and empowering providers as well. Bowen et al. [28] posit system workforce capable of operating value-based care that empowerment adds to the practicality of a policy, models) and knowledge (evidence on value-based care to programme or intervention, as well as enhancing stake- guide policy-makers, providers and payers). holders’ ability to carry out implementation activities. Although most participants perceived Ghana’s data Participants also thought that rewards based on the value infrastructure to be weak, participants also believed of service outcomes could encourage and motivate pro- that the systems have the flexibility to accommodate viders to offer quality healthcare at minimal cost. These the necessary changes to implement VBP. Participants positive effects or benefits may result in more efficient identified the need to upgrade the central-level data and effective allocation and use of healthcare resources system to improve data capture and information-shar- [45]. These findings suggest that a supportive system of ing to facilitate the implementation of the policy. This proper resource management, effective provider motiva- finding matches that of a study conducted by Castaldi tion incentives and citizen empowerment are key factors Issahaku et al. Health Research Policy and Systems (2021) 19:145 Page 12 of 14 that would influence the practicality of a VBP system in a remarkable stakeholder buy-in and willingness to sup- Ghana. port VBP implementation in Ghana. This political will factor was validated by a report of the Economist Intelligence Unit [46] which revealed that countries that choose to restructure their health systems Limitations towards a more patient-centred, value-based model have As the study was conducted during lockdown in Ghana strong political will, and policy-makers are moving in due to COVID-19, almost all the interviews were con- the direction of patient-centric approaches. Moreover, ducted via telephone. The use of telephone-based participants noted that health financing planners could interviews was a limitation of the study, as there were avoid individual and institutional resistance by involv- technical challenges during some interviews, and the ing all stakeholders in the planning and execution of the researcher did not have the opportunity to observe par- policy. Participants indicated that effective systems must ticipants’ body language when responding to questions. be put in place to regulate the activities of all individuals This limitation does not have any impact on the quality and institutions involved. and reliability of the data collected. Another limitation Participants mentioned political interference, resist- was that the perspectives of patients, the community and ance from healthcare providers, poor planning, finan- providers other than doctors, midwives and nurses were cial constraints and inadequate infrastructure as not included in this study. In addition, we cannot draw potential barriers to VBP implantation in Ghana. This conclusions regarding the feasibility of a specific VBP finding is corroborated by Vries et  al. [47], who con- model in Ghana, as we explored a general VBP model. cluded that information asymmetry, lack of start-up Future studies should assess the feasibility of different funding, reluctance to accept financial accountability, models within the Ghanaian context and should also mismatched incentives in healthcare facilities, lack of include the patient and community perspective. Also, all trust due to failed reform attempts, and worsening repu- stakeholders were based in Accra. As a result, this study tation of insurers were barriers to implementation of pay- does not include the perspectives of health system actors ment reform in general, according to the experiences of from other regions and cities in Ghana. participants. Also, the Economist Intelligence Unit [46] found that resistance, fragmented systems and the limi- tations of current healthcare infrastructure and opera- Conclusion tions were some of the barriers that confront countries This study assessed stakeholder perspectives regarding that choose to move towards a more patient-centric, the feasibility of VBP for health financing in Ghana. We value-based model. Conrad et al. [17] also indicated that found that there was potentially high stakeholder accept- deficiency in data infrastructure, regulatory barriers to ance and support for the implementation of VBP in risk-bearing providers, familiarity of providers with FFS Ghana among health system actors. Participants opined payment, and competition among healthcare providers, that VBP could be integrated within the existing health insurers, and the government for various priorities were financing system in Ghana if the necessary supporting barriers to VBP implementation. systems were established and potential implementa- tion constraints overcome. Limited financial and human resources, weak health information and data manage- Implications This study is one of few (if any) studies assessing the fea- ment systems, potential resistance from healthcare pro- sibility of VBP as a potential alternative provider pay- viders and underdeveloped health infrastructure were ment mechanism in Ghana. The outcome of the study identified as potential factors that could impede VBP suggests that the health system of Ghana is flexible and implementation in Ghana. A strong political will and capable of supporting VBP implementation, particularly commitment would be required to incrementally address under the NHIS. However, valid concerns regarding these barriers in order to enhance the feasibility of VBP implementation readiness will need to be considered in within the Ghanaian context. any future VBP model design. A VBP pilot can be carried out through government commitment and support, pub- Abbreviations lic education and stakeholder collaboration. An effective DRG: Diagnosis-related grouping; FFS: Fee-for-service; GDP: Gross domestic payment mechanism is a critical component of financ- product; GHS: Ghana Health Service; LMIC: Low- and middle-income coun-tries; NHIA: National Health Insurance Authority; NHIS: National Health Insur- ing healthcare, as it significantly impacts quality of care ance Scheme; P4P: Pay-for-performance; PHC: Primary healthcare; SSA: Sub- and cost containment. This study also demonstrates the Saharan Africa; UHC: Universal health coverage; VBP: Value-based payment. need to resource and restructure Ghana’s healthcare sys- Acknowledgements tem towards value-based care. The study also unearths Not applicable. I ssahaku et al. Health Research Policy and Systems (2021) 19:145 Page 13 of 14 Authors’ contributions the Ghana National Health Insurance Scheme—a systems approach. AT, OO and JN conceptualized the study. YI and JN designed the study. YI Health Res Policy Syst. 2014;12(1):1–17. https:// doi. org/ 10. 1186/ undertook data collection. YI and GAA analysed and interpreted the data. YI 1478- 4505-1 2- 35. and JN drafted the manuscript. YI, AT, GAA and JN reviewed the manuscript for 10. Amo HFH, Ansah-Adu K, Simpson SNY. The provider payment system intellectual content. All authors read and approved the final manuscript. of the National Health Insurance Scheme in Ghana. 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