ارزیابی عملکرد از گالیم منطقه دوجانبه طرح بیمه سلامت ، منطقه بزرگ آکرا ، غنا

Objective This study assessed performance of the Ga District Mutual Health Insurance Scheme over the period 2007-2009. Methods The desk review method was used to collect secondary data on membership coverage, revenue, expenditure, and claims settlement patterns of the scheme. A household survey was also conducted in the Madina Township by using a self-administered semi-structured questionnaire to determine community coverage of the scheme. Results The study showed membership coverage of 21.8% and community coverage of 22.2%. The main reasons why respondents had not registered with the scheme are that contributions are high and it does not offer the services needed. Financially, the scheme depended largely on subsidies and reinsurance from the National Health Insurance Authority for 89.8% of its revenue. Approximately 92% of the total revenue was spent on medical claims, and 99% of provider claims were settled beyond the stipulated 4-week period. Conclusions There is an increasing trend in medical claims expenditure and lengthy delay in claims settlements, with most of them being paid beyond the mandatory 4-week period. Introduction of cost-containment measures including co-payment and capitation payment mechanism would be necessary to reduce the escalating cost of medical claims. Adherence to the 4-week stipulated period for payment of medical claims would be important to ensure that health care providers are financially resourced to deliver continuous health services to insured members. Furthermore, resourcing the scheme would be useful for speedy vetting of claims and also, community education on the National Health Insurance Scheme to improve membership coverage and revenue from the informal sector.

Many low- and middle-income countries are challenged with how to finance their health care systems to achieve universal coverage of health services. In 2005, the member states of the World Health Organization adopted a resolution encouraging countries to develop health financing systems aimed at providing universal coverage [1]. This was defined as securing access for all to appropriate promotive, preventive, curative, and rehabilitative services at an affordable cost. In the 1990s, a number of mutual health organizations were established in Ghana, with funding and technical support from external partners. Most of these mutual health organizations, however, primarily focused on providing financial protection against the potentially catastrophic costs of a limited range of inpatient services for the disadvantaged people in society [2]. The National Health Insurance Scheme (NHIS) was introduced in 2004 to build on these organizations and provide comprehensive health services to all citizens in Ghana [3]. The National Health Insurance Act, Act 650, was passed into law in Ghana in 2003 through the Legislative Instrument (LI 1809), though implementation in terms of access to benefits began in November 2005 [3], [4] and [5]. Its policy objective is that “within the next five years, every resident of Ghana shall belong to a health insurance scheme that adequately covers him or her against the need to pay out-of-pocket at point of service use in order to obtain access to a defined package of acceptable quality health services” [6]. The NHIS was designed as a mandatory health insurance system, with risk pooling across district schemes, funded from members’ contributions and a levy on the value-added tax charged on selected goods and services [3], [4], [5] and [6].

There are increasing trends in membership coverage and revenue that are largely driven by the exempt groups and subsidies from the NHIA, respectively. The medical claims expenditure is increasing with significant delays in settlement. Introduction of cost-containment measures including co-payments and capitation payment mechanism would be necessary to reduce the escalating cost of medical claims. Adherence to the stipulated 4-week period for claims payment would also be important to ensure that health care providers are financially resourced to deliver continuous health services to insured members. Furthermore, the scheme should be adequately resourced to ensure speedy vetting of medical claims and also to facilitate community education in the district to improve membership coverage and revenue from the informal sector.