In 2004 a community-based health insurance scheme (CBI) was introduced in Nouna district, Burkina Faso. Since its inception, coverage has remained low and dropout rates high. Health workers remain particularly dissatisfied with the current CBI payment scheme, leading to poor perceived quality of care by CBI enrollees and lack of support for the scheme by local health workers.
A discrete choice experiment (DCE) was used to examine CBI provider payment attributes that influence healthcare workers’ stated preferences for an insurance payment mechanism. Conditional logit models with main-effects and interactions terms were used for analysis.
Reimbursement of service fees (adjusted odds ratio (aOR) 1.49, p<0.001) and CBI contributions for medical supplies and equipment (aOR 1.47, p<0.001) had the strongest impact on whether the health workers chose a given payment scenario. The odds of selecting payment scenarios decreased significantly if the scenarios included results-based financing (RBF) payments made through the local health management team instead of directly to health workers (aOR 0.86, p<0.001), or included RBF payments based on CBI coverage outcomes relative to other facilities, rather than on independent evaluations for each facility (aOR 0.86, p<0.001).
Provider payment mechanisms can crucially determine CBI performance, and should be designed taking into account health worker preferences, as done in our study, in order to ensure that CBI objectives are met.
Based on the results from this DCE, a revised CBI payment system will be introduced in Nouna district in January 2011, taking into consideration health worker preferences on how they are paid.