Exploring For-profit Healthcare Providers' Perceptions Of Inclusion In ...

Discussion

The goal of establishing the NHI is to provide reliable and sustainable financing to the health system and achieve UHC in Zambia [34]. In this effort, it is necessary to appropriately consider priority factors such as understanding of the NHI among stakeholders, accreditation processes, financial-related arrangements and information security and management [1,3–5,12,14,15,18]. Knowing where private providers stand concerning these issues may guide inputs on general consensual agreements between the NHI purchaser and private providers to benefit both parties as well as the insured users [35].

Our findings show that private providers need to understand government initiatives that require their engagement. Providers that were undecided or did not want to participate emphasized the need to understand the scheme. On the other hand, those found to be sufficiently aware and decided whether or not to accredit were those in direct contact with NHIMA. Lack of information on the NHI can be identified as a key barrier to the expansion of the scheme, thus indicating the significance of reaching providers through effective communication channels. Similar to this study, findings in Kenya showed that unclear communication from the national hospital insurance fund (NHIF) resulted in providers not knowing how to address concerns and also cited lack of sensitization as proportional to little or no understanding on how the NHIF worked regarding services covered and the requirements for accreditation [1]. Establishing engagement channels with providers, such as continual dialogue through focus group discussions, interviews and other meetings, could be ways of raising awareness as opposed to leaving them to access information on their own. This could also contribute to creating trust and confidence in the NHI scheme.

Our findings also highlight how private providers view their role to public providers. It has been shown in certain LMICs that private providers either offer choice to insured users and complements or supplements the public facilities [1,3,4,36]. Private clinics and hospitals have consistently been reported to offer care under shorter periods compared to the public sector [1,3,18], minimize hindrances and limitations experienced by patients served in the public sector [3,37,38] and generally rank higher in patients’ assessment of hospitality and courtesy of staff, cleanliness of facilities, diagnostic explanations and availability of particular medical inputs [3,39]. These aspects are associated with better quality in the private health sector and were also reported in the current study. Accrediting private providers in the NHI has also been associated with an increase in geographical and demographic coverage, and a potential to expand and reach poor communities where there is limited public delivery [36,37].

Providers reported challenges such as facing rejections delays or unpredictability of claim reimbursements and restrictions on services and products covered in their partnerships with PIC. These challenges are consistent with studies found in both LMIC and HIC settings and mostly regarded payments [1,3,4,7,20,21,36,40,41]. These issues, consistently cited to cause high levels of dissatisfaction and linked with medical service barriers and providers’ “moral hazards” [15], were also obstacles reported as inevitable in the Zambia NHI. An imbalance between revenue generation and number of registered NHI users is also a noteworthy challenge to mention which has also been identified where NHI systems in Africa have been extensively studied [1,15,42,43].

Our findings also highlight the desire for consensual agreements among private providers in their inclusion in the NHI. Reaching these agreements may mean that both purchaser and health providers compromise on certain aspects. For instance, the NHI authority may set accreditation fees in line with what private providers are willing to pay and implement smart verifications systems that may attract private providers [1]. Tailoring information processing and security systems to providers and having centralized and transparent systems may also curb doubts and motivate confidence in the NHI management authorities, as identified across NHI systems such as in Ghana, Kenya and Nigeria [1,7,14,17,18,38,42,43].

Methodological considerations

The sampling process began with stratified selection based on the facility types. However, due to the high number of informants who turned down the invitations for interviews and limited collection time, convenient sampling was subsequently used, which brings with it limitations associated with ad hoc approaches and a tendency to affect evidence quality [29]. The study context was limited to Lusaka out of 117 districts in Zambia due to COVID-19 pandemic travel restrictions, which has a potential to limit the transferability of the findings.