Effect of mobile phone-based health insurance contribution payment system on retention of coverage in the National Health Insurance Scheme in Ghana: an evaluation study.

BACKGROUND: Ghana introduced a mobile phone-based contribution payment system in its national health insurance scheme (NHIS) in December 2018 to improve the process of enrolment. We evaluated the effect of this digital health intervention on retention of coverage in the Scheme, one year after its implementation. METHODS: We used NHIS enrolment data for the period, 1 December 2018-31 December 2019. Descriptive statistics and propensity-score matching method were performed to examine a sample of 57,993 members' data. RESULTS: Proportion of members who renewed their membership in the NHIS via the mobile phone-based contribution payment system increased from 0% to 8.5% whilst those who did so through the office-based system only grew from 4.7% to 6.4% over the study period. The chance of renewing membership was higher by 17.4 percentage points for users of the mobile phone-based contribution payment system, compared to those who used the office-based contribution payment system. The effect was greater for the informal sector workers, males and the unmarried. CONCLUSIONS: The mobile phone-based health insurance renewal system is improving coverage in the NHIS particularly for members who hitherto were less likely to renew their membership. Policy makers need to devise an innovative way for new members and all member categories to enrol using this payment system to accelerate progress towards attainment of universal health coverage. Further study needs to be conducted using mixed-method design with inclusion of more variables.

Prevalence and quality of antihypertensive therapy among hypertension patients enrolled in the Ghana National Health Insurance Scheme.

BACKGROUND: Hypertension is a leading cause of morbidity in Ghana. However, there is insufficient data on the prevalence and quality of antihypertensive therapy. OBJECTIVES: To describe the prevalence of use and quality of antihypertensive therapy. METHODS: A cross-sectional study design was used to analyze the 2015 Ghana National Health Insurance Scheme (NHIS) electronic claims data. Hypertension diagnosis was defined using ICD-10 codes. The primary outcomes assessed were the prevalence of use and quality of antihypertensive therapy. Quality of antihypertensive therapy was defined as the use of antihypertensive agents recommended for treating hypertension patients with comorbid heart failure, myocardial Infarction/Coronary Artery Disease, diabetes, chronic kidney disease or stroke. We used multivariable logistic regression models to identify predictors of antihypertensive use and quality of therapy. RESULTS: Antihypertensive medication use was very high (86%) among the 161 873 hypertension patients covered under the Ghana NHIS. Only a third (32%) of hypertension patients received guideline-concordant therapy. Angiotensin receptor blockers were consumed at the highest dosages of 120 (Interquartile Range [IQR]: 60, 180) daily defined doses over a year. Males (odds ratio [OR] = 0.60; 95% Confidence Interval [CI]:0.58, 0.61) and those with comorbid stroke (OR = 0.91, 95% CI:0.84, 0.99), diabetes (OR = 0.72; 95% CI:0.69, 0.74) and stroke (OR = 0.74, 95%CI:0.68, 0.80) were less likely to use antihypertensives, all other predictors were associated with higher use. CONCLUSION: Antihypertensive medication use was very high among hypertension patients covered under the Ghana NHIS. However, there was indication of suboptimal quality of the antihypertensive therapy provided.

Reducing medical claims cost to Ghana's National Health Insurance scheme: a cross-sectional comparative assessment of the paper- and electronic-based claims reviews.

BACKGROUND: A robust medical claims review system is crucial for addressing fraud and abuse and ensuring financial viability of health insurance organisations. This paper assesses claims adjustment rate of the paper- and electronic-based claims reviews of the National Health Insurance Scheme (NHIS) in Ghana. METHODS: The study was a cross-sectional comparative assessment of paper- and electronic-based claims reviews of the NHIS. Medical claims of subscribers for the year, 2014 were requested from the claims directorate and analysed. Proportions of claims adjusted by the paper- and electronic-based claims reviews were determined for each type of healthcare facility. Bivariate analyses were also conducted to test for differences in claims adjustments between healthcare facility types, and between the two claims reviews. RESULTS: The electronic-based review made overall adjustment of 17.0% from GHS10.09 million (USD2.64 m) claims cost whilst the paper-based review adjusted 4.9% from a total of GHS57.50 million (USD15.09 m) claims cost received, and the difference was significant (p < 0.001). However, there were no significant differences in claims cost adjustment rate between healthcare facility types by the electronic-based (p = 0.0656) and by the paper-based reviews (p = 0.6484). CONCLUSIONS: The electronic-based review adjusted significantly higher claims cost than the paper-based claims review. Scaling up the electronic-based review to cover claims from all accredited care providers could reduce spurious claims cost to the scheme and ensure long term financial sustainability.

The "Universal" in UHC and Ghana's National Health Insurance Scheme: policy and implementation challenges and dilemmas of a lower middle income country.

BACKGROUND: Despite universal population coverage and equity being a stated policy goal of its NHIS, over a decade since passage of the first law in 2003, Ghana continues to struggle with how to attain it. The predominantly (about 70 %) tax funded NHIS currently has active enrolment hovering around 40 % of the population. This study explored in-depth enablers and barriers to enrolment in the NHIS to provide lessons and insights for Ghana and other low and middle income countries (LMIC) into attaining the goal of universality in Universal Health Coverage (UHC). METHODS: We conducted a cross sectional mixed methods study of an urban and a rural district in one region of Southern Ghana. Data came from document review, analysis of routine data on enrolment, key informant in-depth interviews with local government, regional and district insurance scheme and provider staff and community member in-depth interviews and focus group discussions. RESULTS: Population coverage in the NHIS in the study districts was not growing towards near universal because of failure of many of those who had ever enrolled to regularly renew annually as required by the NHIS policy. Factors facilitating and enabling enrolment were driven by the design details of the scheme that emanate from national level policy and program formulation, frontline purchaser and provider staff implementation arrangements and contextual factors. The factors inter-related and worked together to affect client experience of the scheme, which were not always the same as the declared policy intent. This then also affected the decision to enrol and stay enrolled. CONCLUSIONS: UHC policy and program design needs to be such that enrolment is effectively compulsory in practice. It also requires careful attention and responsiveness to actual and potential subscriber, purchaser and provider (stakeholder) incentives and related behaviour generated at implementation levels.

Advancing the application of systems thinking in health: provider payment and service supply behaviour and incentives in the Ghana National Health Insurance Scheme--a systems approach.

BACKGROUND: Assuring equitable universal access to essential health services without exposure to undue financial hardship requires adequate resource mobilization, efficient use of resources, and attention to quality and responsiveness of services. The way providers are paid is a critical part of this process because it can create incentives and patterns of behaviour related to supply. The objective of this work was to describe provider behaviour related to supply of health services to insured clients in Ghana and the influence of provider payment methods on incentives and behaviour. METHODS: A mixed methods study involving grey and published literature reviews, as well as health management information system and primary data collection and analysis was used. Primary data collection involved in-depth interviews, observations of time spent obtaining service, prescription analysis, and exit interviews with clients. Qualitative data was analysed manually to draw out themes, commonalities, and contrasts. Quantitative data was analysed in Excel and Stata. Causal loop and cause tree diagrams were used to develop a qualitative explanatory model of provider supply incentives and behaviour related to payment method in context. RESULTS: There are multiple provider payment methods in the Ghanaian health system. National Health Insurance provider payment methods are the most recent additions. At the time of the study, the methods used nationwide were the Ghana Diagnostic Related Groupings payment for services and an itemized and standardized fee schedule for medicines. The influence of provider payment method on supply behaviour was sometimes intuitive and sometimes counter intuitive. It appeared to be related to context and the interaction of the methods with context and each other rather than linearly to any given method. CONCLUSIONS: As countries work towards Universal Health Coverage, there is a need to holistically design, implement, and manage provider payment methods reforms from systems rather than linear perspectives, since the latter fail to recognize the effects of context and the between-methods and context interactions in producing net effects.

Impact of COVID-19 on the management of hypertension: a perspective on disease severity, service use patterns and expenditures from Ghana's health insurance claims data.

Hypertension is a leading cause of morbidity in Ghana and other sub-Saharan African countries, but management has historically suffered from the fragility of health systems in these countries. This has been exacerbated by the COVID-19 pandemic and its associated measures. Our study examines and quantifies the effect of the pandemic on the management of hypertension in Ghana by determining changes in disease severity and presentation, as well as changes in health service use patterns and expenditures. We used cross-sectional data to perform an impact evaluation of COVID-19 on hypertension management before and during the pandemic. We employed statistical tests including t-tests, z-tests, and exact Poisson tests to estimate and compare hypertension episode intensity and related claim expenditures before and during the pandemic using medical claims data from Ghana's National Health Insurance Authority database. The study duration includes a 12-month reference/pre-pandemic period (March 2019-February 2020) relative to the target/pandemic period (March 2020-February 2021). We observed that although there was a 20% reduction in the number of hypertension claimants in the pandemic year, there was an increase in hypertension severity as measured by the number of hypertension episodes per claimant. There was also an 18.64% or $22.88 (95% CI: $21-$25, p = 0.01042) increase in the average cost per hypertension claimant in the pandemic year. The increase in episodes per claimant had the largest financial impact on the average cost per claimant. The findings from our studies are relevant for future policymaking and strategy implementation for hypertension control in Ghana.

Migrating from user fees to social health insurance: exploring the prospects and challenges for hospital management.

BACKGROUND: In 2003 Ghana introduced a social health insurance scheme which resulted in the separation of purchasing of health services by the health insurance authority on the one hand and the provision of health services by hospitals at the other side of the spectrum. This separation has a lot of implications for managing accredited hospitals. This paper examines whether decoupling purchasing and service provision translate into opportunities or challenges in the management of accredited hospitals. METHODS: A qualitative exploratory study of 15 accredited district hospitals were selected from five of Ghana's ten administrative regions for the study. A semi-structured interview guide was designed to solicit information from key informants, Health Service Administrators, Pharmacists, Accountants and Scheme Managers of the hospitals studied. Data was analysed thematically. RESULTS: The results showed that under the health insurance scheme, hospitals are better-off in terms of cash flow and adequate stock levels of drugs. Adequate stock of non-drugs under the scheme was reportedly intermittent. The major challenges confronting the hospitals were identified as weak purchasing power due to low tariffs, non computerisation of claims processing, unpredictable payment pattern, poor gate-keeping systems, lack of logistics and other new and emerging challenges relating to moral hazards and the use of false identity cards under pretence for medical care. CONCLUSION: Study's findings have a lot of policy implications for proper management of hospitals. The findings suggest rationalisation of the current tariff structure, the application of contract based payment system to inject efficiency into hospitals management and piloting facility based vetting systems to offset vetting loads of the insurance authority. Proper gate-keeping mechanisms are also needed to curtail the phenomenon of moral hazard and false documentation.

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.

A review of the Ghana National Health Insurance Scheme claims database: possibilities and limits for drug utilization research.

BACKGROUND: There are inadequate data on prescribed drug utilization in Sub-Saharan Africa (SSA). Drug utilization research (DUR) in this region is hampered by lack of access to databases that capture prescribed drug utilization such as health insurance claims, electronic medical records and disease registries. The primary objective of this MiniReview was to describe the content of the NHIS claims database in the context of the health care system in Ghana. We will also review the possibilities and limitations of analysing this novel database for drug utilization research (DUR) in Ghana. METHODS: We reviewed the history, composition of the database, coverage and health systems in Ghana. To demonstrate the application of the NHIS claims database for DUR, we reviewed the NHIS' drug formulary (NHIS medicines' list), assessed and quantified the utilization of the top 25 most commonly prescribed medicines and their distributions by age, sex, region of residence and by MDCs. RESULTS: As of December 2014, about 40% (~10.5 million) of the Ghanaian population were active beneficiaries of NHIS. There were 1.43 million unique patients in the NHIS claims database who received services from about 81 providers located in 9 out of the 10 regions in Ghana. The mean age of this sample of beneficiaries was 31 (standard deviation, 22) years, a third of whom were aged <18 years old. Nearly, 2 out of every 3 beneficiaries were females. On average, there were approximately 3 outpatient visits per beneficiary in 2015. There were about 522 unique drugs on the NHIS medicine list. Overall, analgesic was the most prescribed class of medicine (mostly paracetamol and diclofenac). Antimalarials, artemether-lumefantrine, were observed as the second most prescribed medicines followed by anti-infectives (metronidazole) and antihypertensives (amlodipine). CONCLUSION: The Ghana NHIS claims database is a great resource for DUR. This database could also be extended to facilitate pharmacoepidemiological and other health services' research especially if transformed into one of the existing standardized common data models.

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.

Value and Service Quality Assessment of the National Health Insurance Scheme in Ghana: Evidence from Ashiedu Keteke District.

BACKGROUND: Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 to provide financial access to health care for all residents. OBJECTIVES: This article analyzed claims reimbursement data of the NHIS to assess the value of the benefit package to the insured and responsiveness of the service to the financial needs of health services providers. METHODS: Medical claims data reported between January 1, 2010, and December 31, 2014, were retrieved from the database of Ashiedu Keteke District Office of the National Health Insurance Authority. The incurred claims ratio, promptness of claims settlements, and claims adjustment rate were analyzed over the 5-year period. RESULTS: In all, 644,663 medical claims with a cost of Ghana cedi (GHS) 11.8 million (US $3.1 million) were reported over the study period. The ratio of claims cost to contributions paid increased from 4.3 to 7.2 over the 2011-2013 period, and dropped to 5.0 in 2014. The proportion of claims settled beyond 90 days also increased from 26% to 100% between 2011 and 2014. Generally, the amount of claims adjusted was low; however, it increased consistently from 1% to about 4% over the 2011-2014 period. The reasons for claims adjustments included provision of services to ineligible members, overbilling of services, and misapplication of diagnosis related groups. CONCLUSIONS: There is increased value of the NHIS benefit package to subscribers; however, the scheme's responsiveness to the financial needs of health services providers is low. This calls for a review of the NHIS policy to improve financial viability and service quality.

Utilization of healthcare services and renewal of health insurance membership: evidence of adverse selection in Ghana.

BACKGROUND: Utilization of healthcare in Ghana's novel National Health Insurance Scheme (NHIS) has been increasing since inception with associated high claims bill which threatens the scheme's financial sustainability. This paper investigates the presence of adverse selection by assessing the effect of healthcare utilization and frequency of use on NHIS renewal. METHOD: Routine enrolment and utilization data from 2008 to 2013 in two regions in Ghana was analyzed. Pearson Chi-square test was performed to test if the proportion of insured who utilize healthcare in a particular year and renew membership the following year is significantly different from those who utilize healthcare and drop-out. Logistic regressions were estimated to examine the relationship between healthcare utilization and frequency of use in previous year and NHIS renewal in current year. RESULTS: We found evidence suggestive of the presence of adverse selection in the NHIS. Majority of insured who utilized healthcare renewed their membership whiles most of those who did not utilize healthcare dropped out. The likelihood of renewal was significantly higher for those who utilize healthcare than those who did not and also higher for those who make more health facility visits. CONCLUSION: The NHIS claims bill is high because high risk individuals who self-select into the scheme makes more health facility visits and creates financial sustainability problems. Policy makers should adopt pragmatic ways of enforcing mandatory enrolment so that low risk individuals remain enrolled; and sustainable ways of increasing revenue whiles ensuring that the societal objectives of the scheme are not compromised.

Sustainability of recurrent expenditure on public social welfare programmes: expenditure analysis of the free maternal care programme of the Ghana National Health Insurance Scheme.

OBJECTIVE: Sustainability of public social welfare programmes has long been of concern in development circles. An important aspect of sustainability is the ability to sustain the recurrent financial costs of programmes. A free maternal care programme (FMCP) was launched under the Ghana National Health Insurance Scheme (NHIS) in 2008 with a start-up grant from the British Government. This article examines claims expenditure under the programme and the implications for the financial sustainability of the programme, and the lessons for donor and public financing of social welfare programmes. METHODS: Records of reimbursement claims for services and medicines by women benefitting from the policy in participating facilities in one sub-metropolis in Ghana were analysed to gain an understanding of the expenditure on this programme at facility level. National level financial inflow and outflow (expenditure) data of the NHIS, related to implementation of this policy for 2008 and 2009, were reviewed to put the facility-based data in the national perspective. FINDINGS: A total of US$936 450.94 was spent in 2009 by the scheme on FMCP in the sub-metropolis. The NHIS expenditure on the programme for the entire country in 2009 was US$49.25 million, exceeding the British grant of US$10.00 million given for that year. Subsequently, the programme has been entirely financed by the National Health Insurance Fund. The rapidly increasing, recurrent demands on this fund from the maternal delivery exemption programme-without a commensurate growth on the amounts generated annually-is an increasing threat to the sustainability of the fund. CONCLUSIONS: Provision of donor start-up funding for programmes with high recurrent expenditures, under the expectation that government will take over and sustain the programme, must be accompanied by clear long-term analysis and planning as to how government will sustain the programme.

Exploring differences in empirical time preference rates for health: an application of meta-regression.

Estimated time preference rates are extremely varied, with many rates being extremely high. Reviewing empirical studies without quantitative synthesis of their findings is largely unhelpful in determining how rates vary according to different factors. This study therefore explores the use of meta-regression techniques to combine available evidence to draw reliable conclusions about the factors influencing empirical time preference rates. Papers reporting empirically derived time preference rates related to health and health-care programmes were selected. Included were papers presenting all of: a mean time preference rate; information allowing derivation of standard errors; and one or more covariates. Appropriate data were derived from only eight of the 16 papers reporting empirical time preference rates. Meta-regression indicated that there were statistically significant relationships between mean time preference rates and: (a) delay period on a log scale; (b) whether the outcome question related to a gain or a loss. There were a number of limitations related to the use of meta-regression in this area, including difficulties in extracting appropriate data from the original studies, and the extent to which the original studies provide fully deliberated estimates of time preference.