Primary care capitation

Primary care capitation could help improve access and utilisation of primary health care services

Primary care  capitation


o understand the primary care capitation model, it is crucial to first understand what primary care is. It is not a new concept. We have already heard of the commitments of health for all and leave no one behind. Primary care is more than just providing health care services to the community by the primary care workforce, i.e. physicians and allied health workers. A well-functioning primary care requires developing sustainable financial strategies and linking those with the rest of the healthcare system.

It is important to assess the capacity of national institutions to deliver universal health coverage and address any misconceptions about primary care, e.g. it is only for the poor, it provides low-quality care, it is for rural areas and developing countries only, etc.

How well-funded and well-resourced are our frontline services in the public sector? Why talk about capitation model in primary care? Perhaps this model may help stakeholders better understand the role of primary care physician or family physician.

A PCP not only offers treatment for a variety of commonly occurring conditions in all age groups but also provides preventive and diagnostic services. A health plan with a list of services, for instance, routine childhood immunisations, non-communicable diseases management, patient education and counselling, and blood tests offered by a PCP, must be developed and payments for specific services must be defined.

Primary health care is the first point of contact with the health care system. A community-oriented and community-directed programme has the greatest impact on health, particularly among low socio-economic, marginalised or vulnerable populations. A number of developed countries around the world have adopted this model and transformed their healthcare delivery systems.

Stronger and more resilient primary health care systems have been linked to higher patient satisfaction levels and better health outcomes. This improves equity and access to cost-effective primary care services. Numerous studies have supported this theory. The interactions between government purchasers, providers and the general public throughout the health system also determine the role of the PHC sector. Enhancing their PHC systems is a challenging task for low- and middle-income countries.

Another well-known truth is that excessive use of tertiary facilities results from inadequate quality services provided in PHCs. Because of a dearth of comprehensive primary healthcare facilities, people in these areas must rely increasingly on hospitals, even to provide basic PHC services. Health systems across the world have used several PHC finance and payment models in order to address the aforementioned concerns and enhance healthcare access, quality and equity.

Stronger and more resilient primary health care systems have been linked to higher patient satisfaction levels and better health outcomes. These improve equity and access to cost-effective primary care services.

Many nations are moving towards some form of capitation payment for PHC, even though there is no perfect way of reimbursement or payment and each model has advantages and disadvantages. Instead of linking payment to particular diagnostic and therapeutic services when those services are offered, the capitation model is used to finance all essential or necessary health care services (pre-determined) for a given population. Given its ability to guarantee the availability of a care package for the entire population, this payment option is the most in line with PHC’s philosophy of health for all. Such models allow choices for the patients but also provide some financial stability and flexibility for the service providers. Due to financial constraints, the capitation model for PHC is generally being adopted by various countries as fee-for-service and line-item budgets are not as cost-effective.

By incorporating data and information about the health status of the registered population it can improve equity and efficiency. It will also help in reducing burden from secondary and tertiary care by shifting services toward PHC and prevention. This will increase incentives for private providers by attracting more patients.

Evidence suggests that capitation not only contributes to better cost management for both purchasers and providers but also provides accessible and flexible services for patients.

However, there is a risk of under-provision of services and inappropriate referrals. Certain factors, including health needs, geography, vulnerability, deprivation and socio-economic status, should be considered to counterbalance these negative consequences. Implementing additional measures such as monitoring, fee for service and performance-based payments can be added to capitation to improve utilisation of essential services.

Some of the key health concerns like overuse and misuse of medications and the contributing factors like a large number of informal healthcare providers (>600,000), existing profit-led prescribing by general practitioners in Pakistan, as mentioned in a publication in 2022 in Health Sociology Review, can be addressed through a capitation-based model. Furthermore, the incentivisation of physicians by pharmaceuticals will be minimised.

A similar model is under consideration by the Sehat Sahulat card programme to provide PHC services for the population registered with the Benazir Income Support programme in some Pilot Districts of Khyber Pakhtunkhwa. This may work better if it is provided through qualified and trained family physicians having access to an integrated information system. The payments can be adjusted based on demographic variables, geographic differences, poverty and other factors like provision of medicine, transportation and other additional services. Capitated payment system for PHC can be combined with small amounts of fee-for-service, penalties or performance-based payment for essential preventive services, such as antenatal care and immunisation, to counteract the risk of under provision.

There is plenty of evidence in support of the capitation model, which demonstrates that it induces a positive overall effect in terms of the quality of care given by PCP and helps in strengthening PHC. In low-middle income countries where healthcare costs are rising, introducing a capitation model in primary care will be cost-effective. Use of up-to-date clinical guidelines, rational antibiotic prescribing and reduced burden of diseases can then be expected.

Strong governmental and institutional support is needed to bring about such changes.

Dr Hina Jawaid is an associate professor in family medicine at the Health Services Academy, Islamabad

Dr Abdul Jalil Khan is an associate professor in family medicine at Khyber Medical University, Peshawar

Primary care capitation