Author(s) : Huihui Wang, Nathaniel Otoo, and Lydia Dsane-Selby
Affiliated Organization : World Bank
Publication Type : Study Report
Date of publication : 2017
The Ghana National Health Insurance Authority (NHIA) has strengthened its technical capacities over time, developing highly competent professional teams in the fields of actuarial sciences, financial management, insurance mechanisms, and health financing. Building robust actuarial-analysis capacity is crucial to safeguarding the NHIA’s financial sustainability. In addition, a clinical audit division was created in 2009 to review the authenticity of claims and reduce fraud. The government established four claims processing centers to centralize the claims processing, and with support from the Ghana Health Insurance Project (2007–14) the Accra center now also allows for claims to be submitted and processed electronically. A revised NHIS medicine list was introduced to promote rational prescribing practices. The authorities shifted provider payments for inpatient services from a fee-for-service model to Ghana Diagnosis-related-groups (GDRG). A system of capitation1 payment for primary outpatient care was launched in the Ashanti region in 2012 and is cur- rently being rolled out in other regions.
Ghana’s key health indicators improved steadily over the past several decades. In 2013, average life expectancy at birth was 61 years, the maternal mortality rate (MMR) was 321 deaths per 100,000 live births, the total fertility rate (TFR) was 3.9 births per woman, and the under-five mortality (U5M) rate was 67 deaths per 1,000 live births. Moreover, Ghana outperformed the SSA average on each of these indicators. However, the country’s strong overall performance masks significant disparities between income groups.
The government’s efforts to expand the coverage of health services have yielded mixed results. The share of births attended by a skilled health care worker has increased significantly, rising from 47.1 percent in 2003 to 73.7 percent in 2014. However, the coverage rate of modern contraceptives rose only slightly from 18.7 percent in 2003 to 22.2 percent in 2014. Meanwhile, immunization coverage declined between 2008 and 2014, and the share of children with fever taking antimalarial medication was far lower in 2014 than in 2003, before the establishment of the National Health Insurance Scheme (NHIS). The number of outpatient visits increased sharply from 0.5 per capita during 2001–06 to 1.1 per capita during 2011–14.
Despite improvements in some indicators, utilization rates for health services are far from equal across income groups. Coverage rates for modern contraceptives, vaccinations and malaria treatments are relatively equitable, though rates for modern contraceptives and malaria treatment are low for all income groups. The greatest disparity is in the share of births attended by a skilled health care worker; the coverage rate in highest quintile (96.7 percent) is more than double that of lowest quintile (46.9 percent).
There are an estimated 3,500 public, private, and faith-based health care facilities in Ghana. Fifty-seven percent of these facilities are public, 33 percent are private, and 7 percent are operated by the Christian Health Association of Ghana (CHAG). Health facilities include compounds, health centers, clinics, maternity homes, and seven types of hospitals: district, municipal, metropolitan, regional, teaching, psychiatric and uncategorized.
As of February 2016, an estimated 104,652 health care workers were employed by public and CHAG facilities, with nurses comprising the bulk of the workforce. No employment data are available for private facilities.
Eighty-four percent of workers in public and CHAG facilities are health care professionals, 15 percent are administrative officials, and 1 percent are logis- tics specialists. Most health professionals are nurses (59 percent), followed by trainees (13 percent), allied health professionals (13 percent), physician assistants (4 percent), and doctors (4 percent).
The distribution of public health workers is broadly consistent across regions, though the heavily urbanized Greater Accra region and the sparsely populated Upper East and Upper West regions are outliers. Greater Accra has a high num- ber of health workers per capita due to the concentration of doctors in the capital city, while the Upper East and Upper West regions have high numbers of health workers per capita due to their low population density. All other regions have between 2.5 and 2.9 health workers per 1,000 people. No information is available on the distribution of private health workers.
The following health care services are not covered by the NHIS :
Rehabilitation other than physiotherapy; vision, hearing, orthopedic and dental aids and prostheses; elective cosmetic procedures except reconstructive surgery; antiretroviral drugs for treating HIV/AIDS; assisted reproduction, including artificial insemination and hormone- replacement therapy; echocardiography; medical photography; angiography; orthoptics; dialysis for chronic kidney failure; heart and brain surgery except to repair trauma; cancer treatment other than cervical and breast cancer; organ transplants; medicines not included in the NHIS Medicines List; diagnosis and treatment abroad; medical examinations for purposes of employment, school admissions, visa applications, driving licenses, etc.; VIP ward accommodation; and mortuary services.
Private health care providers receive higher GDRG tariffs and capitation rates to compensate for their lack of public funding. Public providers (including Christian Health Association of Ghana [CHAG] facilities) receive funding from the MoH, whereas private providers do not receive it. Consequently, tariff rates differ significantly by facility type and ownership. For example, the reimbursable cost of a general consultation for an adult patient is 76 percent higher for a private primary hospital and 48 percent higher for a private clinic than it is for a public primary hospital.
Survey data show that NHIS members have limited knowledge of the benefits to which they are entitled. About half of NHIS members are aware that enrollees under the age of 18 are exempt from paying premiums; about 70 percent know that pregnant women are exempt; and about 60 percent know that NHIS members are not required to make out-of-pocket payments. However, only 29 percent of NHIS members are aware of all three features. A similar patterns is observed for benefit packages: although 60–70 percent of members are aware of each individual service (antenatal care, postnatal care, childbirth and cash transfers), only 39 percent are aware of all five.
The growth of claims expenditures has outpaced the growth of National Health Insurance Scheme (NHIS) revenue since 2009, causing a sizable deficit. Claims expenditures rose from Ghanaian cedi (GH¢) 7.6 million in 2005 to GH¢1.1 billion in 2014. In 2008, the NHIS had a surplus of GH¢492 million, but in 2009 it began running a deficit each year. By 2014, this deficit had widened to GH¢300 million. The deficit disrupts NHIS operations including its reimbursement schedule, and the situation gets worse when NHI levy contributions are not released on time.
Primary hospitals and public facilities account for the largest share of claims by total value. Fifty-seven percent of outpatient and 90 percent of inpatient claims expenditures are incurred at primary hospitals. Secondary hospital (i.e., Volta regional hospital) accounts for just 3.7 percent of outpatient and 8.3 of inpatient claims, but this share may be larger in regions with more sophisticated secondary and tertiary hospitals. Health centers and private clinics are also major providers of outpatient services, accounting for 21 and 14 percent of outpatient claims expenditures in Volta. Public facilities account for 53 percent of both outpatient and inpatient claims expenditures; faith-based facilities account for 35 percent of inpatient claims and 23 percent of outpatient claims; and private facilities account for 24 percent of outpatient claims and 10 percent of inpatient claims.
Inefficient Claims Processing
Claims processing by NHIA is labor-intensive and inefficient. Claims are vetted on an individual basis. Most claims are evaluated manually, even the relatively small share that are electronically submitted. The NHIA expends a staggering 1,200–4,800 staff weeks vetting each month’s claims, and maintaining this schedule requires hundreds of staff members.
No estimates are available on the quality of claims vetting at the national level, but an analysis of claims in the Volta region suggests that the process is subject to significant errors. The Volta claims data reveal that 18 percent of submitted claims lack essential information or are submitted by unaccredited facilities. These claims should have either been denied or returned to the facility for correction, yet unfulfilled claims represent just 3 percent of the value of all claims in Volta.
Inadequate Monitoring of Service Providers
Previous claims-expenditure reviews have shown that some service providers exhibit abnormal behavior that may indicate fraud or abuse and that warrants additional scrutiny. Private facilities, which tend to be high-cost providers, are more likely than other facilities to submit incomplete claims information. This is especially true for private primary hospitals (figure 5.6). Moreover, among pri- vate clinics that submit claims without GDRG information, 42 percent also lack diagnosis information, making it impossible to determine whether the GDRG is appropriate and these claims expenditure are eligible for reimbursement.
NHIA’s claims-vetting system is not properly equipped to identify abnormal behavior among service providers. Claims offer a wealth of information on expenditure patterns, but most of the data captured by NHIA are not analyzed. There are three obstacles to using claims expenditures to identify abnormal pro- vider behavior.
First, the existing data are not available in a format conducive to analysis. The Volta claims analysis was based on more than 3,000 individual Excel files submitted for 2014 alone. These files are not consistently formatted, and terms are used inconsistently. Addressing these issues is a costly and time- consuming process. While the NHIA has been working to develop standard templates, these issues remain common in all regions.
Second, the data captured by the current system are insufficient to verify the accuracy of the specified GDRG or appropriateness of the treatment.
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