From Fee to Fairness: Designing Risk Adjusted Capitation to Transform Primary Care in Nepal – A Comparative Scoping Review
1
The University of Newcastle, Newcastle, Australia
2
Office of Prime Minister and Councils of Ministers, Government of Nepal, Kathmandu, Nepal
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
BACKGROUND:
As Nepal explore reform to transition from fee-for-service toward more equitable provider payment mechanisms, risk-adjusted capitation has emerged as a promising approach to improve efficiency, equity, and financial protection in primary care as a part of its push for Universal Health Coverage and health purchasing reforms. However, evidence on how risk-adjusted capitation models is designed, implemented, and equity impacts across comparable health systems remains fragmented.
OBJECTIVES:
This study aims to map and synthesis evidence on the design features, risk adjustment approaches, implementation experiences, and reported effects of risk-adjusted capitation models to generate actionable insights for Nepal’s primary care reform.
METHODS:
The comparative scoping review was conducted following JBI methodology and reported in accordance with PRISMA-ScR guidelines. The search was systematically conducted across PubMed, Embase, and web of science, supplemented by Google Scholar. The search strategy focused on identifying studies published between 2010 and 2025 that examines empirical evaluations, modelling studies, policy analysis, and implementation reports in primary care settings. Further, the Population-Concept-Context (PCC) mnemonics was used to inform search strategies with set inclusion and exclusion criteria. Evidence was synthesised using descriptive mapping and thematic analysis.
RESULTS:
The review identified heterogeneous in capitation design and risk adjustment models across high income and low- and middle-income countries. Most used demographic and morbidity adjustments, while advanced models incorporated socioeconomic and geographical indicators. Comparative analysis highlighted substantial variation in data requirements, institutional capacity, and incentives alignment. Evidence suggests that well-designed risk-adjusted capitation can mitigate provider risk selection, enhance resource allocation equity, and strengthen primary care orientation, but implementation challenges remain observable in settings with limited data systems.
CONCLUSIONS:
Risk-adjusted capitation is a promising, context-sensitive reform for Nepal’s primary care system. A phased and simplified risk-adjusted approach, informed by comparative global experiences help to balance financial incentives with equitable health outcomes.
As Nepal explore reform to transition from fee-for-service toward more equitable provider payment mechanisms, risk-adjusted capitation has emerged as a promising approach to improve efficiency, equity, and financial protection in primary care as a part of its push for Universal Health Coverage and health purchasing reforms. However, evidence on how risk-adjusted capitation models is designed, implemented, and equity impacts across comparable health systems remains fragmented.
OBJECTIVES:
This study aims to map and synthesis evidence on the design features, risk adjustment approaches, implementation experiences, and reported effects of risk-adjusted capitation models to generate actionable insights for Nepal’s primary care reform.
METHODS:
The comparative scoping review was conducted following JBI methodology and reported in accordance with PRISMA-ScR guidelines. The search was systematically conducted across PubMed, Embase, and web of science, supplemented by Google Scholar. The search strategy focused on identifying studies published between 2010 and 2025 that examines empirical evaluations, modelling studies, policy analysis, and implementation reports in primary care settings. Further, the Population-Concept-Context (PCC) mnemonics was used to inform search strategies with set inclusion and exclusion criteria. Evidence was synthesised using descriptive mapping and thematic analysis.
RESULTS:
The review identified heterogeneous in capitation design and risk adjustment models across high income and low- and middle-income countries. Most used demographic and morbidity adjustments, while advanced models incorporated socioeconomic and geographical indicators. Comparative analysis highlighted substantial variation in data requirements, institutional capacity, and incentives alignment. Evidence suggests that well-designed risk-adjusted capitation can mitigate provider risk selection, enhance resource allocation equity, and strengthen primary care orientation, but implementation challenges remain observable in settings with limited data systems.
CONCLUSIONS:
Risk-adjusted capitation is a promising, context-sensitive reform for Nepal’s primary care system. A phased and simplified risk-adjusted approach, informed by comparative global experiences help to balance financial incentives with equitable health outcomes.
| eISSN: | 2654-1459 |
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