Presentation (CTI)

OBJECTIVES: Nepal’s move from fee-for-service toward more equitable provider payment mechanisms has highlighted risk-adjusted capitation as a potential strategy to improve efficiency, equity, and financial protection in primary care. Evidence on how risk-adjusted capitation models are designed, implemented, and affect equity across comparable health system is fragmented. Thus, 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 inform 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. Furthermore, the Population-Concept-Context (PCC) mnemonics guided inclusion criteria. Evidence was summarized through descriptive mapping and thematic analysis of payment design, risk adjusted variables, data and institutional requirements, implementation barriers, and equity outcomes.
RESULTS: The review identified heterogeneity in capitation designs and risk adjustment models across high-income and LMICs. Most models used demographic and morbidity adjustments, while advanced models incorporated socioeconomic and geographical indicators. Comparative analysis highlighted wide 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. Conversely, settings with limited data and governance capacity faced implementation challenges, including under‑funding of high need populations and provider resistance.
CONCLUSIONS: Risk-adjusted capitation offers a promising, context sensitive pathway for Nepal’s primary care financing reform. A phased and simplified risk-adjusted approach, informed by comparative global experiences help to balance financial incentives with equitable health outcomes.