ABSTRACT

The incorporation of public and private healthcare providers is considered significant to achieving the goal of universal health coverage, by bringing in the new health financing mechanism based on the social health insurance model. In this regard, the provider payment mechanism plays an important role in efficient and standardized distribution of healthcare, owing to the nature of incentives it generates. Therefore, in this research, I set out to explore the public and private sectors’ experience in their decision to participate in the Sehat Sahulat scheme and the role of incentives, and payment mechanisms in shaping providers’ experience. Additionally, this research also explored the decision to remain with this social health insurance scheme. To achieve my research objectives, I conducted fifteen semi-structured in-depth interviews with the administration and concerned person from nine public and private providers in Rawalpindi and Islamabad districts of Pakistan. The interviews were transcribed, and thematic analysis was performed. Findings demonstrate that providers realize the significance of this scheme and shows interest in enrollment. the biggest motivational factor for public and private sector for join this scheme were their customer demand and social welfare agenda. However, the major constraints due to which both public and private sectors hospital decided to not participate in this scheme were their negative anticipation about the sustainability of the program and state life capacity to fund this program. apart from this, the ascertainment of rates to maintain and provide the quality health-services also discourage them regarding their inclusion decision. Similarly, multiple other factors that put hindrance in public sector empanelment status were seen the presence of different hierarchy for approval, long waiting time for approval, determination of health benefit package cost, absence of proper budgeting and exclusion of input feedback in the rates settlement. Meanwhile, other challenges faced by providers included the inadequacy of the payments rate, the absence of negotiation in the settlement of the rate for the benefits packages and provision of incentives for consultants and other staff members engaged with SSP. These mention challenges hence bring about the discouragement to providers in the decision of continuation with this sehat sahulat program. Their perspective was the in the presence of lowest rates it’s difficult for us to maintain the quality provision of services. Similarly, others challenge providers encountered were regarding the delayed in claims reimbursement with the passage of time and its possible impact on providers operation to run the institution and provision of services in an efficient manner. However, providers also show their concerned on the matter of complaints lodged by patients. They consider such complaints invalid and demands proper investigation system to ensure the validity of complaints before any action by state life. on the other hand, the autonomy to not utilize funds generated under SSP program service provision caused the dissatisfaction among some public providers and impact their working with the scheme.