Positioning the National Health Insurance for financial sustainability and Universal Health Coverage in Ghana: A qualitative study among key stakeholders.

INTRODUCTION: The National Health Insurance Scheme (NHIS) was introduced in 2003 to reduce "out-of-pocket" payments for health care in Ghana. Over a decade of its implementation, issues about the financial sustainability of this pro-poor policy remains a crippling fact despite its critical role to go towards Universal Health Coverage. We therefore conducted this study to elicit stakeholders' views on ways to improve the financial sustainability of the operations of NHIS. METHODS: Twenty (20) stakeholders were identified from Ministry of Health, Ghana Health Services, health workers groups, private medical practitioners, civil society organizations and developmental partners. They were interviewed using an interview guide developed from a NHIS policy review and analysis. All interviews were recorded and transcribed verbatim. The data were analysed thematically with the aid of NVivo 12 software. RESULTS: Stakeholders admitted that the NHIS is currently unable to meet its financial obligations. The stakeholders suggested first the adoption of capitation as a provider payment mechanism to minimize the risk of providers' fraud and protection from political interference. Secondly, they indicated that rapid releases of specific statutory deductions and taxes for NHIS providers could reduce delays in claims' reimbursement which is one of the main challenges faced by healthcare providers. Aligning the NHIS with the Community-based Health Planning and Services and including preventive and promotive health is necessary to position the Scheme for Universal Health Coverage. CONCLUSION: The Scheme will potentially achieve UHC if protected from political interference to improve the governance and transparency that affects the finances of the scheme and the expansion of services to include preventive and promotive services and cancers.

Evaluating services for perinatal asphyxia and low birth weight at two hospitals in Ghana: a micro-costing analysis.

BACKGROUND: Neonatal mortality has been decreasing slowly in Ghana despite investments in maternal-newborn services. Although community-based interventions are effective in reducing newborn deaths, hospital-based services provide better health outcomes. OBJECTIVE: To examine the process and cost of hospital-based services for perinatal asphyxia and low birth weight/preterm at a district and a regional level referral hospital in Ghana. METHODS: A cross-sectional study was conducted at 2 hospitals in Greater Accra Region during May-July 2016. Term infants with perinatal asphyxia and low birth weight/preterm infants referred for special care within 24hours after birth were eligible. Time-driven activity-based costing (TDABC) approach was used to examine the process and cost of all activities in the full cycle of care from admission until discharge or death. Costs were analysed from health provider's perspective. RESULTS: Sixty-two newborns (perinatal asphyxia 27, low-birth-weight/preterm 35) were enrolled. Cost of care was proportionately related to length-of-stay. Personnel costs constituted over 95% of direct costs, and all resources including personnel, equipment and supplies were overstretched. CONCLUSION: TDABC analysis revealed gaps in the organization, process and financing of neonatal services that undermined the quality of care for hospitalized newborns. The study provides baseline cost data for future cost-effectiveness studies on neonatal services in Ghana. FUNDING: Authors received no external funding for the study.

Parental costs for in-patient neonatal services for perinatal asphyxia and low birth weight in Ghana.

The major causes of newborn deaths in sub-Saharan Africa are well-known and countries are gradually implementing evidence-based interventions and strategies to reduce these deaths. Facility-based care provides the best outcome for sick and or small babies; however, little is known about the cost and burden of hospital-based neonatal services on parents in West Africa, the sub-region with the highest global neonatal death burden. To estimate the actual costs borne by parents of newborns hospitalised with birth-associated brain injury (perinatal asphyxia) and preterm/low birth weight, this study examined economic costs using micro-costing bottom-up approach in two referral hospitals operating under the nationwide social health insurance scheme in an urban setting in Ghana. We prospectively assessed the process of care and parental economic costs for 25 out of 159 cases of perinatal asphyxia and 33 out of 337 cases of preterm/low birth weight admitted to hospital on the day of birth over a 3 month period. Results showed that medical-related costs accounted for 66.1% (IQR 49% - 81%) of out-of-pocket payments irrespective of health insurance status. On average, families spent 8.1% and 9.1% of their annual income on acute care for preterm/LBW and perinatal asphyxia respectively. The mean out-of-pocket expenditure for preterm/LBW was $147.6 (median $101.8) and for perinatal asphyxia was $132.3 (median $124). The study revealed important gaps in the financing and organization of health service delivery that may impact the quality of care for hospitalised newborns. It also provides information for reviewing complementary health financing options for newborn services and further economic evaluations.