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Umfang: 1 online resource (68 pages)

Ausgabe: 1st ed.

Serie: World Bank Studies

Inhalt: Ghana National Health Insurance Scheme (NHIS) was established in 2003 as a major vehicle to achieve the country's commitment of Universal Health Coverage. The government has earmarked value-added tax to finance NHIS in addition to deduction from Social Security Trust (SSNIT) and premium payment. However, the scheme has been running under deficit since 2009 due to expansion of coverage, increase in service use, and surge in expenditure. Consequently, Ghana National Health Insurance Authority (NHIA) had to reduce investment fund, borrow loans and delay claims reimbursement to providers in order to fill the gap. This study aimed to provide policy recommendations on how to improve efficiency and financial sustainability of NHIS based on health sector expenditure and NHIS claims expenditure review. The analysis started with an overall health sector expenditure review, zoomed into NHIS claims expenditure in Volta region as a miniature for the scheme, and followed by identifictation of factors affecting level and efficiency of expenditure. This study is the first attempt to undertake systematic in-depth analysis of NHIS claims expenditure. Based on the study findings, it is recommended that NHIS establish a stronger expenditure control system in place for long-term sustainability. The majority of NHIS claims expenditure is for outpatient consultations, district hospitals and above, certain member groups (e.g., informal group, members with more than five visits in a year). These distribution patterns are closely related to NHIS design features that encourages expenditure surge. For example, year-round open registration boosted adverse selection during enrollment, essentially fee-for-service provider mechanisms incentivized oversupply but not better quality and cost-effectiveness, and zero patient cost-sharing by patients reduced prudence in seeking care and caused overuse. Moreover, NHIA is not equipped to control expenditure or monitor effect of cost-containment policies. The claims processing system is mostly manual and does not collect information on service delivery and results. No mechanisms exist to monitor and correct providers' abonormal behaviors, as well as engage NHIS members for and engaging members for information verification, case management and prevention.

Anmerkung: Front Cover -- Contents -- Acknowledgments -- About the Authors -- Abbreviations -- Chapter 1 Introduction -- Background -- Objective -- Methodology and Data -- Organization of the Book -- Notes -- Chapter 2 The Country Context and Key Features of the Ghanaian Health Sector -- Country Context -- Health Outcomes -- Health Services -- Health Service Delivery System -- Health Financing System -- Notes -- Chapter 3 NHIS Overview -- Basic Features -- NHIS's Role in Health Care Financing -- Notes -- Chapter 4 NHIS Claims-Expenditure Review -- Trends in NHIS Claims Expenditures over Time -- Overview of Claims Expenditures in the Volta Region -- Claims Expenditure Distribution and Variation, by Provider -- Claims Expenditure Distribution and Variation, by Member Characteristics -- Examples of Potential Cost Saving Areas -- Summary -- Note -- Chapter 5 Factors Affecting Level and Efficiency of Claims Expenditures -- Behaviors of Service Providers and NHIS Members -- NHIA Internal Management -- Chapter 6 Designing Policies for Efficient Spending -- Recommendations -- Areas for Further Analytical Work -- Boxes -- Box 3.1 NHIS Exclusions -- Box 3.2 NHIA Accreditation Criteria -- Box 5.1 Key Formatting Issues for NHIS Claims Data -- Figures -- Figure 1.1 Development Indicators and Health Statistics in the Volta Region -- Figure 2.1 Equity in Health Outcomes, 2003-14 -- Figure 2.2 Ghana's Global Rank on Key Economic and Health Indicators, 1990-2013 -- Figure 2.3 Coverage of Essential Services, by Wealth Quintiles, 2003-14 -- Figure 2.4 Health Care Facilities, by Ownership -- Figure 2.5 Number of Health Workers per 1,000 People, by Region, 2016 -- Figure 2.6 The Flow of Funds in the Ghanaian Health Sector -- Figure 2.7 Per Capita Total Health Spending, 2005-12 -- Figure 2.8 Financing Sources of Total Health Expenditure, 2005-12. , Figure 3.1 NHIS Revenue Composition, 2005-14 -- Figure 3.2 NHIS Expenditure Composition, 2014 -- Figure 3.3 NHIS Membership Composition, 2014 -- Figure 3.4 NHIS Coverage, by Wealth Quintiles, 2008-14 -- Figure 3.5 NHIA Claims-Processing Flowchart -- Figure 3.6 Knowledge of NHIS Enrollment Features among NHIS Members -- Figure 3.7 Knowledge of NHIS Benefits among NHIS Members -- Figure 3.8 Public Health Financing, by Mechanism, 2014 -- Figure 3.9 Spending on MoH and NHIS as a Share of Total Public Spending, 2010-14 -- Figure 3.10 Public Spending on Goods and Services, by Recipient, 2012-15 -- Figure 4.1 NHIS Revenues and Expenditures, 2005-14 -- Figure 4.2 NHIS Balance and Changes in Investment Fund Assets -- Figure 4.3 NHIS Loan Balance and Interest Payments -- Figure 4.4 Claims Expenditures, by Service Type, Volta, 2014 -- Figure 4.5 Claims Expenditures, by GDRG, Volta, 2014 -- Figure 4.6 Distribution of Claims Expenditures, by Facility Type, Volta, 2014 -- Figure 4.7 Distribution of Claims Expenditures, by Facility Ownership, Volta, 2014 -- Figure 4.8 Per-Claim Expenditures, by Facility Type and Ownership, Outpatient Services -- Figure 4.9 Per-Claim Expenditures, by Facility Type and Ownership, Inpatient Services -- Figure 4.10 Per-Claim Expenditure on Outpatient Services among Primary Hospitals -- Figure 4.11 Per-Claim Expenditures on Inpatient Services among Primary Hospitals -- Figure 4.12 Benefit Incidence, by Membership Category, Volta, 2014 -- Figure 4.13 NHIS Members and Claims Expenditures, by Number of Outpatient Visits, Volta, 2014 -- Figure 4.14 NHIS Members and Claims Expenditures, by Number of Inpatient Admissions, Volta, 2014 -- Figure 4.15 Per-User Expenditures on Outpatient Services, by Age Group, Volta, 2014 -- Figure 4.16 Per-User Expenditures on Inpatient Services, by Age group, Volta, 2014. , Figure 4.17 Per-User Expenditure on Outpatient Services, by Member Category, Volta, 2014 -- Figure 4.18 Per-User Expenditure on Inpatient Services, by Member Category, Volta, 2014 -- Figure 5.1 Age Group Composition of Population Census, NHIS Member as of January 2014 and NHIS Members Continuously Enrolled for 12 Months -- Figure 5.2 NHIS Membership Attrition, January 2014-January 2015 -- Figure 5.3 Proportion of NHIS Members Continuously Enrolled for 12 Months in 2014, by Age Group -- Figure 5.4 Proportion of Members Utilizing Services in Volta, by Membership Renewal Tendency, 2014 -- Figure 5.5 Features of NHIS Claims Administration -- Figure 5.6 Share of Claims with Incomplete Information, by Facility Type and Ownership, Volta, 2014 -- Tables -- Table 1.1 Data Sources -- Table 2.1 Health Outcome Indicators in Ghana, 1960-2013 -- Table 2.2 Coverage of Essential Services, 2003-14 -- Table 2.3 Health Care Facilities, by Type -- Table 3.1 Tariff Rates for Selected DRGs, by Facility Type -- Table 4.1 Changes in the Total Claims Expenditures, by Component -- Table 4.2 Simulated Savings from Redistributing Outpatient Claims Expenditures -- Table 5.1 Labor Requirements Simulation for Processing One Month's NHIS Claims.

Weitere Ausg.: ISBN 1-4648-1117-2

Weitere Ausg.: ISBN 1-4648-1118-0

Sprache: Englisch