2014年-世界发展银行全球_Universal_Health_Coverage_for_Inclusive_and_Sustainable_Development___Country_Summary_Report_for_Ghana_17页_317kb

Summary of the Japan-World Bank Partnership Program for Universal Health Coverage: Ghana Country Report

Core Content

This report provides an overview of Ghana's progress toward Universal Health Coverage (UHC) as part of the Japan-World Bank Partnership Program, highlighting the country's experiences, challenges, and lessons learned in the implementation of its National Health Insurance Scheme (NHIS).

Main Points

1. Overview of Ghana

• Population: Approximately 25 million (as of 2010).
• Economic Status: Lower middle-income country with a GNI per capita of $1,410 (PPP) in 2011.
• Health Indicators: Life expectancy at birth is 65 years; HIV/AIDS prevalence is among the lowest in Sub-Saharan Africa.
• Health System: A multilevel system with public and private providers, including faith-based institutions.
• NHIS: Established in 2003 via Act 650, with a revised version in 2012 (Act 852) to integrate district mutual health insurance schemes (DMHISs) into a unified system.

2. Current Status of NHIS

• Population Coverage: 36% of the population (about 8.9 million) were covered in 2012.
• Benefits: Comprehensive coverage includes outpatient and inpatient services, maternity care, and oral health. Excluded services include non-medically necessary treatments and some high-cost services.
• Financial Protection: The NHIS accounts for 18% of total health spending. It does not have cost-sharing mechanisms like copayments or deductibles.
• Funding Sources:
  • 72.8% from a 2.5% levy on VAT.
  • 17.4% from social security contributions.
  • 4.5% from premiums.
  • 5.3% from investment income, grants, and other sources.
• Out-of-Pocket Spending: Still accounts for 37% of total health expenditure, with only 1.4% of households facing catastrophic health spending in 2006.

3. Health Financing and Cost Management

• Fiscal Space: Increased from 0.93% of GDP in 2004 to 1.68% in 2008 due to fiscal expansion and HIPC initiative.
• Cost Challenges: Rising utilization and claims have led to increased costs, particularly in pharmaceuticals (accounting for 50% of NHIS spending).
• Payment Systems:
  • Initially used an itemized fee-for-service model.
  • Transitioned to a Diagnosis-Related Groups (G-DRG) system in 2008, but outpatient claims still dominate.
  • Piloting a capitation payment system for primary care.

4. Equity and Redistribution

• Progressivity: The health financing system is largely progressive due to general taxes, but utilization of benefits is pro-rich.
• Premium Structure: Geographically and socially differentiated, with exemptions for the elderly, children, retirees, and indigents.
• Coverage Gaps: Despite exemptions, some wealthy individuals may still benefit from subsidies, while the poor may be excluded due to subjective criteria and lack of outreach.
• Redistribution: Premiums are now collected into a central pool and distributed based on need, improving equity.

5. Human Resources for Health (HRH)

• Workforce Distribution: Urban areas and hospitals have higher density of health workers compared to rural and northern regions.
• HRH Ratios:
  • Physicians: 0.1 per 1,000 population.
  • Nurses: 0.39 per 1,000 population.
  • Midwives: 0.15 per 1,000 population.
• Training and Retention: Training of physicians is inadequate, and retention in rural and remote areas remains a challenge.
• Incentives: The government has introduced bonding schemes and financial incentives to improve retention and distribution.

6. Sequencing of Reforms

• Transition from CBHI: The NHIS evolved from pilot CBHI schemes in the early 1990s to a national system.
• Design and Implementation: The NHIS was designed in 2003, with Act 852 in 2012 integrating district schemes into a unified system.
• Policy Debates: Major disagreements occurred over the structure and funding sources of the NHIS, leading to compromises such as exempting formal sector workers from paying premiums if they contribute through social security.

Key Lessons

• Inclusive Design: The NHIS needs to be re-evaluated to ensure it reaches the informal sector and the most vulnerable populations.
• Cost Containment: The current payment systems, particularly the G-DRG model, have not effectively contained costs, especially for outpatient services.
• Equity in Access: While the system is designed to be progressive, the benefits are not equally utilized by all population groups.
• Human Resource Strategy: There is a need for more balanced recruitment and retention of key health workers, especially in underserved regions.
• Operational Efficiency: Improving the efficiency of the NHIS through better management and technology (e.g., eclaims and instant card issuance) is crucial for sustainability.

Conclusion

The NHIS has made significant strides in expanding health coverage and reducing financial barriers to care, but challenges remain in achieving full UHC, particularly in reaching the informal sector and ensuring equitable access and cost management. The country's experience offers valuable insights for other nations pursuing similar health reforms.