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Capitation Payment Method as A Policy Tool, Versus Fee for Services, for the Financial Sustainability of The National Health Insurance in Sudan: Algadarif State Case Study.
Mr.Ammar Alasha1

Abstract
Moving away from Fee-For-Services payment method in the National Health Insurance fundAlgadarif State to capitation, is an important step towards averting the financial sustainability problem of the scheme associated with such payment method. The objectives of this study are to analyze the cash flow and the financial status of the National Health Insurance-Algadarif State during the last five years (2008-2012), and to evaluate the financial status during the years 2013-2017 if the Fee for Services payment method changes into capitation payment method for the outpatient care services. The study tries to calculate the per capita rate by using top-down allocation method and then investigates the financial sustainability in three different scenarios; Scenario (A) The total revenues increase according to the trend in the past and the total health expenditures under the current Fee-for-Services expected inflation rate 30%,. Scenario (B) the same as (A) but the outpatient paid under capitation payment method adjusted to the same inflation rates. Scenario (C) same as scenario (B) but the revenues increase by 2% in each coming year.2013-2017. The methods used by the study are based on cash flow analysis, trend analysis, growth ratio method and per capita calculation method. Data used for analyzing total revenues, total expenditures and calculating per capita rate are obtained from the financial and coverage records of the NHIF-Algadarif State during the year 2008-2012 and the actual outpatient expenditures data are obtained from the providers in the year 2012. The findings indicate that, the financial gap for the years 2008-2012 are negative except in the year 2008 and 2009, therefore the expected financial gap are negative in the three scenarios except when the outpatient paid according to its actual provider's cost. Moreover introducing capitation for outpatient care services will decrease the NHIF-Algadarif State expenditures by 14% of Fee for Services for the coming year 2013-2017, at the same time the providers can continue gaining profit by 32% of their actual outpatient cost in same years. Key words: Capitation, Fee-for Services, Financial Sustainability, National Health Insurance Fund in Sudan, Algadarif State.
1

Masters Student, Health Economics and Health Care Management Program, Chulalongkorn University ; E-mail: alashamar@yahoo.com

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Introduction
Over the past sixteen years, since government of Sudan embraced a National Health Insurance Fund (NHIF)scheme as a policy aims at; promoting equitable access, improving quality of the curative medical services and raising revenues for the health sector, issues of escalating expenditure on health services against limited resources has become more and more prominent putting the financial sustainability2 of the scheme under great pressure and high risk .However, until relatively recently, a little had been written on these issues and a little actions had been taken on the real ground to know and treat some of root causes of this fatal issue. The National Health Insurance in Sudan, and at the level of Executive Directorates which represent the Health insurance scheme in the State, has been suffering from many issues that threatening its financial stability, and may lead to a disastrous reduction in capacity for functioning and producing an effective benefit for both users and stakeholders over time. Firstly, the enrollment unit of the health insurance scheme is the family that usually includes 5-7member/family in the State, the average monthly premium for a family is range between 9-30 SDG and the average cost of medical services that provided per member between 25-35 SDG monthly (4-6$), so when we compare the average premium with the average cost we can notice the vast gap between them. Moreover, the utilization rate per member is 2times/year, and this rate is relatively high comparing with the standards. Secondly, the actual obtained premium has been paid by the Federal and state Ministry of Finance as employers which equivalent 10% of an employee's salary (Civil Servant) varies between 50-70% of the approved government budget. Thirdly, the decision of the President in 2010, considers the health facilities that are owned and under supervision of the health insurance scheme to divert its ownership to the Ministry of Health, accordingly the health insurance scheme will only acts as purchaser, at the same time those health facilities are experienced as an effective tool for cost containment Finally, the health insurance Fund in the State as well as in all Sudan, has been used to compensate for providers by fee for services, and no doubt this method can lead to escalation of the health care expenditure, as it financially incentives the providers to overutilization of the health care services, regarding to prescribing an unnecessary services, corrupted claims and supplier induced demand (SID) which always taken a place. The above mentioned factors can lead to either increasing the health care expenditures, or decreasing the scheme's revenues. Find a solution is our challenge, and it is not possible to solve this issue through those factors linked to economic crises, or the President decision, so this enforce us to select the provider payment arena to enable the scheme be self financially sustainable.
The scheme is financially sustainable when the revenues exceed the expenditures or at least the scheme at the breakeven point.
2

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Figure 1: The Total Revenues and the claim paid by the State 2006-2011

! depicts the total revenues of the State and the claims paid for the providers in million SDG, for the years 2006-2011 under FFS as the dominant payment mechanism, we can notice the gap is getting smaller and smaller over this period. Moreover, the expenditure was not included the other expenses eg.operational

Objective and Scope

Objectives The objectives of this study are to; 1. Analyze the existing situation of the revenues both government and non-government revenue and the health care expenditures. 2. Project for revenues and the health expenditures of both government and non-government budget after changing the payment method onto capitation. 3. Come up with the per capita rate that would allow NHIF Algadarif State to be financially sustainable. 4. Compare between the capitation and Fee- for-Services as a mix payment method for purchasing health services, with the current Fee-For-Services method in term of financial sustainability. Scope The study makes an attempt to analyze the financial status of the NHIF - Algadarif state before changing the current FFS payment mechanism into capitation payment mechanism in term of financial ratio and financial gap for the year 2008-2012 The capitation will be used for the outpatient care services, that including; Medical Doctors visit, Medical, Assistants visit, Specialist consultation, laboratory

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investigations services, diagnostic services (x-ray, us scanning) and the prescribed drugs. The inpatient care services will remain paid under fee-for-services.

Literature Review
There are many studies concerned about capitation payment method comparing with the other payment methods in term of cost, access, utilization, satisfaction etc. Benjamin T. et al(2009) conducted a study that analyzed the financial effect of capitation system on total knee and total hip, and the study found that, in the first year after implementation of capitation system, cost for hospital decreased by 26%.Winnie C and Siripen S. et al.(2001) conducted study in Thailand, attempted to detect the impact of capitation payment system which adopted by Social Security Scheme(SSS) on the use of resources, the study revealed that, SSS patient in general use fewer resources with capitation when compare to Fee-ForServices payment method. Catalano R. et al (2000) conducted a study comparing the cost of mental health services for children and youth under FFS, and under capitation, the authors concluded that compared to FFS, capitation reduces health service costs. Joan R. et al (2002) conducted study in Colorado, to examine cost and access for mental illness patient services for two group of patient, the first group the providers paid under FFS and the second group the providers paid under capitation payment mechanism, and the variable measured are services cost, utilization and access, study found that cost per person was reduced under capitation payment compare to patient under FFS and by the end of year two cost reduced by two-third comparing capitation to FFS, and the access also reduced. Gosden T. et al.(2003) Conducted a before and after study, investigating whether a change in payment mechanism from capitation to capitation and fee-for services, lead to significant change in primary care physician activities,. The author concluded that physician activities increased and referral rates decreased under capitation and FFS payment method

Conceptual Framework
The current financial sustainability of the National Health Insurance- Algadarif State will be measured in term of financial gap and financial ratio3. The financial gap represents the surplus or deficit of the revenues4 over expenditures5 by using cash flow analysis in the years 2008-2012. The current financial ratio will be measured using the data of total assets and total liabilities in the year 2012, the total current
3

Measure the ability of the scheme to pay its debts for the next 12 month, the normal ratio should be 1.5-3, the higher current ratio indicates the financial status is healthy. 4 Categorized into government revenues and non-government revenues 5 Includes the direct health expenditures(outpatient and outpatient) and the indirect health expenditures (labor, capital and material cost)

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assets include; cash in vault, cash in bank, account receivable and inventories (drugs, medical equipment, land, vehicles etc.), the total current liabilities include; account payable for health services, maintenance, repair, and compensation and allowance. Forecasting for expenditures and revenues for the years 2013-2017, will depends mainly on the data collected for the years 2008-2012 by defining its growth ratio and by using the trend analysis, then the revenues and expenditures in the year 2012 will be used as a base for forecasting the coming revenues and expenditures. The forecasted expenditures, firstly will represents the current situation under FFS payment method, secondly, will represent the new situation under capitation payment method for the outpatient care services and thirdly will represent the actual providers cost. Calculation for per capita rate will depend on top-down allocation for the outpatient care service. Data for the year 2012, displays the actual providers cost of outpatient care services will be used. The inpatient care services will remains paid under Fee-for services. The revenues and expenditures will be adjusted to the events might take a place in the future, followed by measuring and comparing the forecasted financial gaps under the different payment method.

Study methods
For the current situation analysis in the years 2008-2012, the total revenues and the total expenditures for each year will be calculated, and then we can come up with the financial status in term of financial gap by the following equation: FG = TR-TE Where FG = Financial Gap TR = Total Revenues TE=Total Expenditures Financial status in term of current ratio for the year 2012 can be given by the following equation: Current Financial Ratio = Calculating the per capita rate for the outpatient care services in the year 2012, the study will use top-down allocation by the following equation: Per Capita Rate = The forecasted situation under the capitation payment mechanism to be more consistency, assumptions to reflect the possible events that may take a place in the future should be considered, include: 1) The revenues will be treated as its trend in the past but will increase only by the average growth rate [68]

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2) The expenditures will increase by the expected inflation rate (30%) 3) Stakeholders will support the new payment mechanism, and the providers will not going to change their behaviors. To fulfill the above target, three different scenarios are considered, that include; Scenario (A) the revenues for the year 2013-2017, will increases according to the trend in the past, and the actual expenditures under FFS will increase by the inflation rate. Scenario (B) the same as (A) but the capitated outpatient services adjusted to increase by the expected inflation rate Scenario (C) the same as (A), but the actual provider's outpatient cost adjusted to the expected inflation rate.

Research Results
The results of the study depend mainly on the conceptual framework, design and assumptions. The current financial status: The financial gap for the years 2008-2012 is 2,395.08 , 109.850 , -1,865.41 , 1,865.6 , -1,198.61 million SDG, so the NHIF-Algadarif State had a surplus in the years 2008 and 2009, then incurred deficit in the years 2010,2011 and 2012, that means its financially unsustainable during the last three years.(Table 1). The financial sustainability in term of current financial ratio in the year 2012, the study found that, the total current assets of the State is 40,787.7 million SDG and the total liabilities is 28,253.96 Million SDG, so the current financial ratio; Table 1: Revenues, Expenditures and Financial Gap in the years 2008-2012 2002 2002 2010 2011 2012

Total Revenues

11,594.3 14,587.0 8 2

15,618.8 6

19,261.7 0

27,642.2 6

Average Growth rate 18,395.43 24.9%

Average amount

Expenditures Outpatient Care *Services 530.023 G.P Consultati on 7.151 M.A

891.122

1,040.63

1,350.76

1,411.94

953.133

%22.20

17.437

20.038

3.752

34.611

16.598

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Consultati on Specialist Consultati on Laborator y Investigati ons Diagnostic Services Medicines

281.046

351.184

452.421

225.543

327.101

327.459

728.682

976.889

1,214.03

1,830.48

2,641.01

1,478.22

249.116 3,784.5 7 5,580.5 9 1,326.6 9 (14.4%) 2,292.0 3

351.506 3,851.96 6,440.09 4,283.20 (29.6%) 3,753.88

351.501 6,303.91

427.021 7,948.07

495.76

374.982

40.6%

Total Outpatient Services Total Inpatient Expenditures Total Indirect Health Expenditures Total Expenditures Financial Gap TR-TE The current Financial Ratio

13,591.6 7,096.02 35.9% 1 9,382.53 11,785.63 18,502.0 10,338.1 3 3,167.08 5,363.52 6,885.89 4,205.27) (18.1%) (25.4%) (23.9%) 4,934.39 3,948.15 3,452.95 3,676.28 15.7%

9,199.3 14,477.1 17,484.0 21,097.30 28,840.8 18,219.73 34% 0 7 0 2,395.0 109.85 - 478.89 8 1,865.41 1,835.60 1,198.61 =1.4

That means for every one million SDG the NHIF-Algadarif State owes, it has 1.4 available in current assets, but this current ratio indicates that the scheme has some financial stress as the healthy current ratio is range between 1.5-2. (Barton A, 2005) Outpatient per capita rate: Per capita rate for the outpatient care services, and after defining the capitation package that going to be paid under the new capitation payment method, the study used TopDown allocation method by assigning the specified amount of budget allocated to the package in the year 2012 and then divided by the number of eligible clients all over the State. (Table 2) [70]

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Outpatient per Capita Rate = 34.3 SDG

That means the NHIF-Algadarif State should pay for the providers 34.3 SDG for each individual enrolled in the scheme for the outpatient care services. Table 2: Per Capita Rate for Outpatient Services Amount SDG Total outpatient Budget Total Number of Clients Outpatient Per Capita amount Outpatient Care Services -G.P Consultation -M.A Consultation -Specialist Consultation -Laboratory Investigation -Diagnostic Services -Medicines 15,960.00 465.631 34.3 5.6 0.8 4.9 5.4 1.1 16.5

Total Expenditures

15,960.1 2,607.53 372.505 2,281.6 2,514.4 512.194 7,682.9

100% 16% 2.2% 14% 15.8% 3% 49%

Forecasted financial status: The financial sustainability of the scheme in the years 2013-2017, depends mainly on the scenarios developed by the study. In scenario (A) that indicates the revenues increased by the growth rate in the past and the expenditures under the current Fee-for-Services payment method adjusted to the expected inflation rate 30%, the study found that the NHIF-Algadarif State will incur deficit if continue on the bureaucratic payment system in the years 2013-2017 by -2,797.9 , -6,559.4 , 9,086.3 , -13,416.0 and -18,447.0 million SDG respectively, therefore the scheme in order to be financially sustainable should either decrease the expenditure or increased the revenues for the years 2013-2017 by 8%, 15%, 17%, 19% and 21% respectively, the average is 16%.(Table 3) For scenario (B) that indicates the revenues increase as in scenario (A), and the outpatient care services paid under the capitation payment method adjusted to 30% inflation rate, the findings show the NHIF-Algadarif State financial gap for the years 2013-2017 will be 506.57, -1,283.7, -3,561.6, -6,157.9 and 9,045.1 million SDG respectively, so the scheme and for its financial sustainability should either decrease the expenditures or increase the revenues in the years 2013-2017 by 0%, 3%, 7%, 9% and 10% respectively, the average is 6%(Table 4) Table 3: The Forecasted Revenue and Expenditures 2013-2017, Scenario (A)

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Actual Revenues and Expenditur es 2012 2013 27,642.2 34,695.2 (100) (100) 28,840.8 (100) 18,519.6 (64) 1,411.94 (4.9) 34.611 (0.1) 327.101 (1.2) 495.76 (1.7) 2,641.0 (9.2) 13,591.6 (46.6) 6,885.9 (24) 229.04 37,493.1 (100) 24,052.6 (64.1) 1,835.52 (4.9) 44.994 (0.1) 425.231 (1.2) 644.488 (1.7) 3,433.3 (9.1) 17,669.1 (46.5) 8,951.7 (23.8) 329.82 [72] Forecasted Revenues

*Total Revenues

Total Expenditures

* Outpatient Expenditure

G.P Consultation

MA Consultation Specialist Consultation

Diagnostic Services

Laboratory Investigations

2014 43,181. 6 (100) 48,741. 0 (100) 31,268. 4 (64.2) 2,386.1 8 (4.9) 58.493 (0.1) 552.80 1 (1.2) 837.83 4 (1.7) 4,463.3 (9.1) 22,969. 8 (45.6) 11,637. 2 (23.8) 474.94

2015 54,277. 1 (100) 63,363. 4 (100) 40,648. (64) 3,102.0 3 (4.9) 76.040 (0.1) 718.64 1 (1.2) 1,089.1 8 (1.7) 5,802.3 (9.1) 29,860. 8 (46.6) 15,128. 3 (24) 683.91

2016 68,954.4 (100) 82,372.4 (100) 52,843.6 (63.9) 4,032.7 (4.9) 98.852 (0.1) 934.233 (1.2) 1,415.9 (1.7) 7,542.9 (9.1) 38,818.9 (46.6) 19,666.8 (23.8) 984.83

2017 88,601. 0 (100) 107,048 . (100) 68,696. 7 (64) 5,242.3 (4.9) 128.508 (0.1) 1,214.5 (1.2) 1,840.7 (1.7) 9,805.8 5 (9.1) 50,464. 7 (46.5) 25,566. 8 (24) 1,418.1

Medicines

Inpatient Expenditures

Admission Services

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(0.8) Surgical Operations 1,388.27 (4.8) 5,268.58 (18.3) 3,452.9 (12) 1,875.33 (6.5) 129.47 (0.4) 250 (0.9) 1,198.15 (4.1) -1,198.5 (8%) (0.8) 2,082.4 (4.8) 7,376.01 (18.3) 4,488.8 (12) 2,437.9 (6.4) 168.417 (0.4) 325 (0.9) 1,557.6 (4.1) -2,797.9 (15%) (0.8) 3,123.6 1 (4.8) 10,326 (18.3). (0.8) (0.8) 6 (0.8) 10,542. 1 (4.76) 28,335. 6 (18.3) 12,820. 6 (12.8) 6,962.9 (6.4) 480.512 (0.4) 928.23 (0.9) 4,448.6 (4.1) 18,447. 0 (16%)

4,685.4 7,028.1 (4.8) (4.8) 20,239.7 (18.3) 9,861.9 (12) 5,356.1 (6.5) 364.7 (0.4) 714.02 (0.9) 3,422.0 (4.1) -13,418. (21%)

Other inpatient Health Expenditures *Indirect health Expenditures

14,456. 9 (18.3) 5,835.5 7,586.1 (12) (12) 3,169.3 (6.4) 218.65 (0.4) 422.5 (0.9) 2,024.8 (4.2) 6,559.4 (17%) 4,120.1 (6.5) 284.4 (0.4) 549.25 (0.9) 2,632.3 (4.1) 9,086.3 (19%)

Labor cost Material Cost Capital Cost Expenditures Balance(TR-TE) financial gap6

The scenario (C) indicates the financial sustainability if the revenues increased by the same pattern in the past and the outpatient expenditures from the provider's perspective adjusted to inflation rate 30%. The study found the financial gap for NHIF Table 4: The Forecasted Revenues and Expenditures 2013-2017, Scenario (B) Actual Forecasted Revenues Revenues 2012 2013 2014 2015 2016 *Total Revenues 27,642.2 34,695. 43,181. 54,277.1 68,954. 2 6 4
6

2017 88,601. 0

Financial Gap percentage indicates, the percentage of the financial gap of the total revenues, in the forecasted years

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Total Expenditures 26,298.9 (100) 15,960.1 (64) 2,607.5 (4.9) 372.505 (0.1) 2,270.6 (1.2) 2,514.4 (1.7) 512.194 (9.2) 7,682.9 (46.6) 6,885.9 (24) 229.04 (0.8) 1,388.27 (4.8) 5,268.58 (18.3) 3,452.9 (12) 34,188. 7 (100) 20,748. 1 (64.1) 3,389.7 5 (4.9) 484.25 6 (0.1) 2,951.8 (1.2) 3,268.8 (1.7) 665.85 (9.1) 9,987.8 (46.5) 44,465. 3 (100) 26,972. 6 (64.2) 4,406.7 (4.9) 57,12.34 75,112. (100) 3 (100) 35,064.3 45,583. (64) 6 (63.9) 5,728.7 7,447.3 (4.9) (4.9) 818.393 (0.1) 4,988.5 (1.2) 5,524.1 (1.7) 1,125.3 (9.1) 16,879.3 (46.6) 1,063.9 (0.1) 97,646. 1 (100) 59,258. 7 (64) 9,681.5 (4.9) 1,383.1 (0.1) 8,430.6 (1.2) 9,335.8 (1.7) 1,901.8 (9.1) 28,526. 1 (46.5) 25,566. 8 (24) 1,418.1 6 (0.8) 10,542. 1 (4.76) 28,335. 6 (18.3) 12,820. 6 (12.8)

* Outpatient Expenditure

G.P Consultation

MA Consultation

Specialist Consultation Diagnostic Services Laboratory Investigations Medicines

Inpatient Expenditures

Admission Services

629.53 3 (0.1) 3,837.3 (1.2) 4,249.3 (1.7) 865.61 (9.1) 12,984. 1 (45.6) 8,951.7 11,637. (23.8) 2 (23.8) 329.82 474.94 (0.8) (0.8)

6,485.1 (1.2) 7,181.4 (1.7) 1,462.8 (9.1) 21,943. 1 (46.6) 15,128.3 19,666. (24) 8 (23.8) 683.91 984.83 (0.8) (0.8) 7,028.1 (4.8) 20,239. 7 (18.3) 9,861.9 (12)

Surgical Operations

Other inpatient Health Expenditures *Indirect health Expenditures

2,082.4 3,123.6 4,685.4 (4.8) 1 (4.8) (4.8) 7,376.0 10,326 14,456.9 1 (18.3). (18.3) (18.3) 4,488.8 5,855.5 7,586.1 (12) (12) (12)

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Labor cost Material Cost Capital Cost Expenditures Balance(TR-TE) Financial gap (1) Health 1,875.33 (6.5) 129.47 (0.4) 250 (0.9) 1,198.15 (4.1) 1,343.30 2,437.3 (6.4) 168.33 (0.4) 325 (0.9) 1,557.6 (4.1) 5 506.57 (0%) -3,561.6 1,283.7 (7%) (3%) 3,169.3 (6.4) 218.82 (0.4) 422.5 (0.9) 2,024.8 (4.2) 4,120.1 (6.5) 248.41 (0.4) 549.25 (0.9) 2,632.3 (4.1) 5,356.1 (6.5) 369.21 (0.4) 714.02 (0.9) 3,422.1 (4.1) -6,157.9 -9,045.1 (9%) (10%) 6,962.9 (6.4) 480.32 (0.4) 928.23 (0.9) 4,448.6 (4.1)

at Algadarif State in the years 2013-2017 will be 5,531.7 , 5,222.96 , 4,864.4 , 4,622.0 , 4,831.6 million SDG respectively, and this high figures indicate that, the providers are gaining high profits and the NHIFAlgadarif State is mainly bearing the risk under Fee-For-Services payment mechanism if we comparing the actual outpatient expenditures from the NHIF perspective, with the actual cost from the providers perspective.(Table 5) Table 5: The forecasted Revenues and Expenditures 2013-2017, Scenario (C) Actual Forecasted Revenues Revenues and actual Expenditure s 2012 2013 2014 2015 2016 *Total Revenues 27,642.2 34,695. 43,181.6 54,277. 68,954. 2 1 4 Total Expenditures 22,475.7 29,163. 37,958.6 49,412. 64,332. (100) 4 (100) 7 4 (100) (100) (100) * Outpatient Expenditure 12,069.8 15,690. 20,398.8 26,517. 34,472. (53) 9 (53) 9 6 (53) (53) (53) 754.532 1,623.7 1,867.29 2,147.3 2,469.4 G.P Consultation (4.9) 3 (4.9) 8 9 [75]

2017 88,601.0 83,769.4 (100) 44,814.9 (53) 2,839.92 (4.9)

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(4.9) 39.80 (0.1) 376.17 (1.2) 330.36 5 (1.1) 3,073.1 5 (9.1) 12,995. 7 (46.5) 8,951.7 (23.8) 329.82 (0.8) 2,082.4 (4.8) 7,376.0 1 (18.3) 4,488.8 (12) 2,437.3 (6.4) 168.33 (0.4) 325 (0.9) 1,557.6 (4.1) 5 5,233.6 (4.9) 52.64 (0.1) 497.48 (1.2) 558.31 7 (1.1) 4,016.6 3 (9.1) 21,959. 2 (46.6) 15,128. 3 (24) 683.91 (0.8) 4,685.4 (4.8) 14,456. 9 (18.3) 7,586.1 (12) 4,120.1 (6.5) 248.41 (0.4) 549.25 (0.9) 2,632.3 (4.1) (4.9) 60.53 (0.1) 572.10 (1.2) 725.81 2 (1.1) 4,619.1 3 (9.1) 28,547. 0 (46.6) 19,666. 8 (23.8) 984.83 (0.8) 7,028.1 (4.8) 20,239. 7 (18.3) 9,861.9 (12) 5,356.1 (6.5) 369.21 (0.4) 714.02 (0.9) 3,422.1 (4.1) 5

MA Consultation Specialist Consultation Diagnostic Services

10.176 (0.1) 127.579 (1.2) 254.127 (1.1) 928.438 (9.2) 9,995.1 (46.6) 6,885.9 (24) 229.04 (0.8) 1,388.27 (4.8) 5,268.58 (18.3) 3,452.9 (12) 1,875.33 (6.5) 129.47 (0.4) 250 (0.9) 1,198.15 (4.1)

45.77 (0.1) 432.59 (1.2) 429.475 (1.1) 3,492.72 (9.1) 16,891.7 (45.6) 11,637.2 (23.8) 474.94 (0.8) 3,123.61 (4.8) 10,326 (18.3). 5,855.5 (12) 3,169.3 (6.4) 218.82 (0.4) 422.5 (0.9) 2,024.8 (4.2)

69.62 (0.1) 657.92 (1.2) 943.562 (1.1) 5,311.99 (9.1) 37,111.1 (46.5) 25,566.8 (24) 1,418.16 (0.8) 10,542.1 (4.76) 28,335.6 (18.3) 12,820.6 (12.8) 6,962.9 (6.4) 480.32 (0.4) 928.23 (0.9) 4,448.6 (4.1)

Laboratory Investigations

Medicines

Inpatient Expenditures

Admission Services Surgical Operations Other inpatient Health Expenditures *Indirect health Expenditures Labor cost Material Cost Capital Cost Expenditures Balance(TR-TE) Financial gap (1)

5,531.7 5,222.96 4,864.4 4,622.0 4,831.6 [76]

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Conclusion
The study findings show that if the NHIF-Algadarif State chooses to continue paid the outpatient care services under FFS, the financial gap in the coming years 2013-2017 will be -2,797.9, -6,559.4, 9,086.3, -13,418.0 and -18,447.0 million SDG respectively. To achieve the financial sustainability the NHIFAlgadarif State has to decrease the expenditures or increase the revenues in coming years 2013-2017 by 8%, 15%, 16%, 19% and 20% respectively. Moreover, the providers will gain profit by 8,361.66, 10,870.18, 14,150.32, 18,370.6 and 23,881.8 million SDG respectively, these profits represent 53% of their actual outpatient expenditures in each coming year. By introducing capitation payment method for the outpatient care services ,the study found that, the financial gap in coming years 2013-2017 will be 506.570, -1,283.7, -3,561.6, -6,157.9 and -9,045.1 million SDG respectively, so in order the NHIF-Algadarif State achieve its financial sustainability has no need to increase or decrease its revenues in the year 2013 as the revenue is almost near the breakeven point, but the State has to decrease the expenditures or increase the revenues for the year 2013-2017 by only 0%, 3%, 6%, 9% and 10% respectively Introducing capitation for the outpatient care services will decrease the expenditures in the years 2013-2017 comparing with FFS by 3,304.5, 4,295.8, 5,583.7, 7,259.9 and 9,437.9 million SDG respectively and that represent 14% of total outpatient expenditures for each coming year. Moreover, the providers will continue gaining profit in the years 2013-2017 by 5,057.2, 6,574.4, 8,546.7, 11,110.6, 14,443.84 million SDG respectively and these profits represent 32% of their actual outpatient expenditures for coming years. The study, and according to the results, will suggest changing the outpatient payment mechanism from Fee-for-services onto capitation in order to be closer to achieve the financial sustainability of the scheme.

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