Benefit-cost analysis of electronic claims processing under Ghana's National Health Insurance Scheme.

OBJECTIVE: The aim of this study was to evaluate the benefit-cost of E-claims. A benefit-cost analysis was used to evaluate the efficiency of E-claims from the perspective of the providers and the purchaser. DESIGN: A benefit-cost analysis approach was taken for this economic evaluation. Furthermore, we estimated the incremental benefit-cost ratio (IBCR) of the intervention under assessment. PARTICIPANTS: Purchasers and healthcare providers of the National Health Insurance Scheme (NHIS) of Ghana were the study population. RESULTS: The analysis was stratified according to providers and purchaser. Cost incurred in processing claims electronically and manually were estimated by assessing the resource use and their corresponding costs. Sensitivity analysis was conducted to assess the robustness of the results to variations in discount rate and proportions of claims processed under E-claims compared with paper claims. The combined sample of providers and purchaser made incremental gains from processing claims electronically. The IBCR was -19.75, 25.56 and 5.10 for all (sample) providers, purchaser and both providers and purchaser, respectively. When projected for the 330 facilities submitting claims to the NHIS claims processing centre (CPC) as at December 2014, the IBCR were -35.20, 25.56 and 90.06 for all providers, purchaser and both providers and purchaser. The results were sensitive to the discount rate used and proportions of E-claims compared with paper claims. CONCLUSION: Electronic processing of claims is more efficient compared with manual processing, hence provide an economic case for scaling it up to cover many more healthcare facilities and NHIS CPCs in the Ghana.

An Analysis of Catastrophic Out-of-Pocket Health Expenditures in Ghana.

Introduction: Ghana implemented a universal health coverage scheme aimed at attaining financial risk protection against catastrophic out-of-pocket health expenditures. The effort has yielded mixed benefits for the different socio-economic profiles of the population. The present study estimates the incidence of catastrophic payments among Ghanaian households. Methods: The study analyzed the round seven dataset of the Ghana Living Standards Survey collected between 2016 and 2017. We estimated the incidence and intensity of catastrophic payments for total household consumption and non-food consumption for a range of thresholds. The analysis further weighted the measures of catastrophic payments to determine the distribution sensitivity. Results: As the threshold increased from 10 to 25% of total household consumption, the incidence of catastrophic payments dropped from 1.0 to 0.1%. At the 40% threshold of non-food consumption, the estimated incidence was 0.2%. For both total household consumption and non-food consumption, the concentration indices were negative at all the thresholds. The results were indicative of a higher concentration of financial catastrophe among the poorest households and significant inequalities in the incidence between the poorest and richest households. Conclusion: The study confirmed the declining trend in the general incidence of catastrophic health expenditures in Ghana. However, the incidence and risk of financial catastrophe remained disproportionately higher among the poorest households, which is instructive of gaps in financial risk protection coverage. The Ghana National Health Insurance Scheme must therefore strengthen its targeting and enrolment of this sub-population group to reduce their vulnerability to catastrophic payments.

Evaluating the impact of the national health insurance scheme of Ghana on out of pocket expenditures: a systematic review.

BACKGROUND: Approximately 150 million people suffer from financial catastrophe annually because of out-of-pocket expenditures (OOPEs) on health. Although the National Health Insurance Scheme (NHIS) of Ghana was designed to promote universal health coverage, OOPEs as a proportion of total health expenditures remains elevated at 26%, exceeding the WHO's recommendations of less than 15-20%. To determine whether enrollment in the NHIS reduces the likelihood of OOPEs and catastrophic health expenditures (CHEs) in Ghana, we undertook a systematic review of the published literature. METHODS: We searched for quantitative articles published in English between January 1, 2003 and August 22, 2017 in PubMed, Google Scholar, Economic Literature, Global Health, PAIS International, and African Index Medicus. Two independent authors (J.S.O. & S.E.) reviewed the articles for inclusion, extracted the data, and conducted a quality assessment of the studies. We accepted the World Health Organization definition of catastrophic health expenditures which is out of pocket payments for health care which exceeds 20% of annual house hold income, 10% of household expenditures, or 40% of subsistence expenditures (total household expenditures net food expenditures). RESULTS: Of the 1094 articles initially identified, 7 were eligible for inclusion. These were cross-sectional household studies published between 2008 and 2016 in Ghana. They demonstrated that the uninsured paid 1.4 to 10 times more in out-of-pocket payments (OOPs) and were more likely to incur CHEs than the insured. Yet, 6 to 18% of insured households made catastrophic payments for healthcare and all studies reported insured members making OOPs for medicines. CONCLUSION: Evidence suggests that the national health insurance scheme of Ghana over the last 14 years has made some impact on reducing OOPEs, and yet healthcare costs remain catastrophic for a large proportion of insured households in Ghana. Future studies need to explore reasons for the persistence of OOPs for medicines and services that are covered under the scheme.

Mundane? Demographic characteristics as predictors of enrolment onto the National Health Insurance Scheme in two districts of Ghana.

BACKGROUND: In 2003, Ghana passed a law to establish a National Health Insurance Scheme (NHIS) to serve as the main vehicle for achieving universal health coverage. Over 60% of the population had registered by 2009. Current active membership is however 40%. The stagnation in growth has been recorded across all the membership categories. Clearly, the Scheme is falling short of its core objective. This analysis is a critical thematic contextual examination of the effects of demographic factors on enrolment onto the Scheme. METHODS: Demographic secondary data for 625 respondents collected (using a structured questionnaire) during a cross-sectional household survey in an urban, Ashaiman, and rural, Adaklu, districts was analyzed in univariate and multivariate logistic regression models using Statistical Package for Social Scientists (SPSS). Statistical significance was set at P-value < 0.05. Variables included in the analysis were age, gender, education, occupation and knowledge about the NHIS. RESULTS: Seventy-nine percent of the survey respondents have ever enrolled onto the NHIS with three-fifths being females. Of the ever enrolled, 63% had valid cards. Age, gender and educational level were significant predictors of enrolment in the multivariate analysis. Respondents between the ages 41-60 years were twice (p = 0.05) more likely to be enrolled onto a district Scheme compared with respondents between the ages 21-40 years. Females were thrice (p = 0.00) more likely to enroll compared with males. Respondents educated to the tertiary, five times (p = 0.02), and post-graduate, four times (p = 0.05), levels were more likely to enroll compared with non-educated respondents. No significant association was observed between occupation and enrolment. CONCLUSION: Uptake of the scheme is declining despite high awareness and knowledge. Leadership, innovation and collaboration are required at the district Scheme level to curtail issues of low self-enrolment and to grow membership. Otherwise, the goal of universal coverage under the NHIS will become merely a slogan and equity in financial access to health care for all Ghanaians will remain elusive.

Policy initiation and political levers in health policy: lessons from Ghana's health insurance.

BACKGROUND: Understanding the health policy formulation process over the years has focused on the content of policy to the neglect of context. This had led to several policy initiatives having a still birth or ineffective policy choices with sub-optimal outcomes when implemented. Sometimes, the difficulty has been finding congruence between different values and interests of the various stakeholders. How can policy initiators leverage the various subtle mechanisms that various players draw on to leverage their interests during policy formulation. This paper attempts to conceptualise these levers of policy formulation to enhance an understanding of this field of work based on lived experience. METHODOLOGY: This is a qualitative participant observation case study based on retrospective recollection of the policy process and political levers involved in developing the Ghana National Health Insurance Scheme. The study uses a four-concept framework which is agenda setting, symbols manipulation, constituency preservation and coalition building to capture the various issues, negotiations and nuanced approaches used in arriving at desired outcomes. RESULTS: Technical experts, civil society, academicians and politicians all had significant influence on setting the health insurance agenda. Each of these various stakeholders carefully engaged in ways that preserved their constituency interests through explicit manoeuvres and subtle engagements. Where proposals lend themselves to various interpretations, stakeholders were quick to latch on the contentious issues to preserve their constituency and will manipulate the symbols that arise from the proposals to their advantage. Where interests are contested and the price of losing out will leave government worse off which will favour its political opponent, it will push for divergent interests outside parliamentary politics through intense negotiations to build coalitions so a particular policy may pass. CONCLUSIONS: This paper has examined the policy environment and the political leverages in retrospect at arriving at Ghana's health insurance policy and design. New perspectives have been brought to the dynamics of the interactions of the 3 streams of problem, policy and politics. It provides lessons which suggest that in understanding the policy process, it is important that actors engage with the content as well as the context to understand viewpoints that may be expressed by interest groups. This will empower policy proponents to achieve easier results and limit the frustrations associated with the policy process. There are no straight and determined pathways for achieving outcomes so appreciating the evidence and basis for design, negotiation process and building coalitions along the way are skills to be mastered.

The cost of health professionals' brain drain in Kenya.

BACKGROUND: Past attempts to estimate the cost of migration were limited to education costs only and did not include the lost returns from investment. The objectives of this study were: (i) to estimate the financial cost of emigration of Kenyan doctors to the United Kingdom (UK) and the United States of America (USA); (ii) to estimate the financial cost of emigration of nurses to seven OECD countries (Canada, Denmark, Finland, Ireland, Portugal, UK, USA); and (iii) to describe other losses from brain drain. METHODS: The costs of primary, secondary, medical and nursing schools were estimated in 2005. The cost information used in this study was obtained from one non-profit primary and secondary school and one public university in Kenya. The cost estimates represent unsubsidized cost. The loss incurred by Kenya through emigration was obtained by compounding the cost of educating a medical doctor and a nurse over the period between the average age of emigration (30 years) and the age of retirement (62 years) in recipient countries. RESULTS: The total cost of educating a single medical doctor from primary school to university is 65,997 US dollars; and for every doctor who emigrates, a country loses about 517,931 US dollars worth of returns from investment. The total cost of educating one nurse from primary school to college of health sciences is 43,180 US dollars; and for every nurse that emigrates, a country loses about 338,868 US dollars worth of returns from investment. CONCLUSION: Developed countries continue to deprive Kenya of millions of dollars worth of investments embodied in her human resources for health. If the current trend of poaching of scarce human resources for health (and other professionals) from Kenya is not curtailed, the chances of achieving the Millennium Development Goals would remain bleak. Such continued plunder of investments embodied in human resources contributes to further underdevelopment of Kenya and to keeping a majority of her people in the vicious circle of ill-health and poverty. Therefore, both developed and developing countries need to urgently develop and implement strategies for addressing the health human resource crisis.

E-health: determinants, opportunities, challenges and the way forward for countries in the WHO African Region.

BACKGROUND: The implementation of the 58th World Health Assembly resolution on e-health will pose a major challenge for the Member States of the World Health Organization (WHO) African Region due to lack of information and communications technology (ICT) and mass Internet connectivity, compounded by a paucity of ICT-related knowledge and skills. The key objectives of this article are to: (i) explore the key determinants of personal computers (PCs), telephone mainline and cellular and Internet penetration/connectivity in the African Region; and (ii) to propose actions needed to create an enabling environment for e-health services growth and utilization in the Region. METHODS: The effects of school enrolment, per capita income and governance variables on the number of PCs, telephone mainlines, cellular phone subscribers and Internet users were estimated using a double-log regression model and cross-sectional data on various Member States in the African Region. The analysis was based on 45 of the 46 countries that comprise the Region. The data were obtained from the United Nations Development Programme (UNDP), the World Bank and the International Telecommunications Union (ITU) sources. RESULTS: There were a number of main findings: (i) the adult literacy and total number of Internet users had a statistically significant (at 5% level in a t-distribution test) positive effect on the number of PCs in a country; (ii) the combined school enrolment rate and per capita income had a statistically significant direct effect on the number of telephone mainlines and cellular telephone subscribers; (iii) the regulatory quality had statistically significant negative effect on the number of telephone mainlines; (iv) similarly, the combined school enrolment ratio and the number of telephone mainlines had a statistically significant positive relationship with Internet usage; and (v) there were major inequalities in ICT connectivity between upper-middle, lower-middle and low income countries in the Region. By focusing on the adoption of specific technologies we attempted to interpret correlates in terms of relationships instead of absolute "causals". CONCLUSION: In order to improve access to health care, especially for the majority of Africans living in remote rural areas, there is need to boost the availability and utilization of e-health services. Thus, universal access to e-health ought to be a vision for all countries in the African Region. Each country ought to develop a road map in a strategic e-health plan that will, over time, enable its citizens to realize that vision.